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HYSICAL DIAGNOSIS 




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LIBRARY OF CONGRESS. 



Chap........ Copyright No... 

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UNITED STATES OF AMERSCA. 



ESSENTIALS 



OF 



PHYSICAL DIAGNOSIS 



OF THE 



THORAX. 



BY 

ARTHUR M. COR WIN, AM., M.D., 

Demonstrator of Physical Diagnosis in Rush Medical College; 

Attending Physician to the Central Free Dispensary, 

Department of Rhinology, Laryngology, 

and Diseases of the Chest. 



SECOND EDITION, REVISED AND ENLARGED, 




] tfaM - B-i 



PHILADELPH] 
W. B. SAUNDERS, 

925 Walnut Street. 
1896. 

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Copyright, 1896, 
By W. B. SAUNDERS. 



ELEOTROTYPED BY PRESS OF 

WESTOOTT & THOMSON, PHILADA. W, B. SAUNDERS, PHILADA. 



PREFACE TO THE SECOND EDITION. 



The first edition of this book, published under the title 
" Outline of Physical Diagnosis of the Thorax," was chiefly 
intended to meet the immediate wants of my classes. From 
its rapid distribution it has seemed to have reached a wider 
field. The present edition under the new title, as published 
by Mr. Saunders, is a revision of the original text, with an 
added section setting forth the signs found in each disease 
of the chest. 

In the preparation of this synopsis I have availed myself 
of the works of the best writers upon Diagnosis, General 
Medicine, Physiology, and Anatomy, from which I have 
endeavored to cull the essentials of the subject in hand. 

To Drs. Wm. R. Parkes and John Edwin Rhodes I desire 
to express my thanks for their valued services rendered in 
the reading of the proof. 

A. M. C. 



PREFACE TO THE FIRST EDITION. 



The following outline aims to present in systematic form 
the gist of the science of physical diagnosis as applied to the 
thorax. 

In this form it is hoped that the salient points of the sub- 
ject may be the more readily grasped by those who are all 
too busy, while in medical college, to seek them out of ex- 
tensive treatises and to arrange them for proper assimilation. 

It is designed to meet the immediate demands of the 
student, and to be a further guide to a more elaborate study 
of the theme as set forth in existing literature, and as fur- 
nished in the clinical material of public and private practice. 

While the intention has been to confine the subject to the 
thorax, reference lias been made to some of the abdominal 
organs, and to various phenomena of the circulatory system 
outside of the chest, where these have seemed to be specially 
related to the chest cavity and its organs. 

I am indebted to Drs. John M. Dodson, James B. Her- 
rick, John Edwin Rhodes, and George H. Weaver for sug- 
gestions in the correction of proof. 

A. M. C. 




Fig. 1.— Corwin's Double Binaural Stethoscope. 




Fig. 2.— Corwin's Multiplex Stethoscope. 




Fig. 3.— Folded Single Stethoscope. 



THE 



PHYSICAL DIAGNOSIS OF THE CHEST. 



THE 

PHYSICAL DIAGNOSIS OF THE CHEST. 



Definition. — Physical Diagnosis is the science and art of 
objective examination of the body as practised upon its 
surface. 

The science of physical diagnosis deals with the character, 
causes, and significance of physical signs, and the methods 
of eliciting them. Sic/ns are objective features, as distin- 
guished from symptoms, which are purely subjective. 

The art of physical diagnosis is the practical applica- 
tion of the science. Its aim is, therefore, to distinguish ob- 
jectively between health and disease, and between various 
diseases. 

Introductory Note. — Objective examination, though deal- 
ing in a broad way with the entire body, finds its most profit- 
able application to the thorax, which is therefore the field of 
its operation as considered in the following synopsis. The 
four divisions of the subject are (1) Topography of the Chest ; 
(2) Landmarks of the Chest ; (3) Methods of Physical Diag- 
nosis ; (4) Physical Signs common in and peculiar to each 
Disease of the Chest, 



17 



18 



PHYSICAL DIAGNOSIS OF THE CHEST. 
TOPOGRAPHY OF THE CHEST. 



The topography of the chest deals with the regions, their 
boundaries and their contents. 







Fig. 4.— Anterior surface of the chest. 



ANTERIOR REGIONS. 



SUPRA-CLAVICULAR regions. 
Boundaries : 

ABOVE, the line drawn from the junction of the ex- 
ternal with the middle third of the clavicle to a point 
at the inner margin of the sterno-mastoid muscle, on 
a level with the upper ring of the trachea. 
BELOW, the superior border of the inner two-thirds 

of the clavicle. 
INTERNALLY, the anterior border of the sterno- 
cleido-mastoid muscle. 
Contents : the apices of the lungs ; parts of the sub- 



TOPOGRAPHY OF THE CHEST 19 

clavian and carotid arteries ; and the subclavian and 
jugular veins, on either side. 

CLAVICULAR regions. 

Boundaries : the margins of the inner two-thirds of the 

clavicle. 
Contents : 

MIGHT SIDE, the apex of the lung. 
EXTERNALLY, the subclavian artery. 
INTERNALLY, the innominate artery and recurrent 
laryngeal nerve. 
LEFT SIDE, the apex of the lung. 

EXTERNALLY, parts of the subclavian vessels. 
INTERNALLY, parts of the subclavian and carotid 
vessels. 

INFRA-CLAVICULAR regions. 
Boundaries : 

ABOVE, the lower border of the clavicle. 

BELOW, the lower border of the third rib. 

INTERNALLY, the border of the sternum. 

EXTERNALLY, a line let fall from the junction of 
the middle with the outer third of the clavicle, and 
passing down an inch to the outer side of the nipple 
(some authorities give the mammillary line). 
Contents : 

EITHER SIDE, lung tissue. 

BIGHT SIDE, a part of the aorta, descending vena 
cava, and right bronchus. 

LEFT SIDE, the pulmonary artery and left bronchus, 
the base of the heart and great vessels. 

MAMMARY regions. 
Boundaries : 

ABOVE, the lower border of the third rib. 
BELOW, the lower border of the sixth rib. 
INTERNALLY, the margin of the sternum. 
EXTERNALLY, a line let fall from the junction of 



20 PHYSICAL DIAGNOSIS OF THE CHEST. 

the middle with the outer third of the clavicle, passing 
an inch to the outer side of the nipple. 
Contents : 

BIGHT SIDE, the lung, right lobe of the liver, right 
auricle, right ventricle, and diaphragm. 

LEFT SIDE, the lung and heart. 

INFRA-MAMMARY regions. 
Boundaries: 

ABOVE, the lower border of the sixth rib. 
BELOW, the lower border of the false ribs and car- 
tilages (the costal arch). 
IKTEBKALLY, the costal arch. 

EXTEBNALLY, a line let fall from the junction of 
the middle with the outer third of the clavicle. 
Contents : 

BIGHT SIDE, the lung on deep inspiration, the right 

lobe of the liver. 
LEFT SIDE, the lung and the left lobe of the liver. 

SUPRA-STERNAL region. 
Boundaries : 

ABOVE, a line on a level with the first ring of the 

trachea. 
BELOW, the inter-clavicular notch. 
LATEBALLY, the anterior borders of the sterno- 
cleido-mastoid muscles. 
Contents : the trachea, thyroid gland, vessels, and oesoph- 
agus. 

SUPERIOR STERNAL region. 
Boundaries : 

ABOVE, the inter-clavicular notch. 
BELOW, a line on a level with the third costal car- 
tilages. 
LATEBALLY, the margins of the sternum. 
Contents : the lung below the level of the second costal 



TOPOGRAPHY OF THE CHEST 21 

cartilage, the descending vena cava, aorta, pulmonary 
artery, and bifurcation of the trachea. 

INFERIOR-STERNAL region includes the sternum below 
the level of the third costal cartilages. 
Contents : a part of the right auricle and the origins of 
the pulmonary artery and aorta ; a small part of the 
left lung ; a part of the right ventricle, right lung and 
liver, and a part of the attachment of the pericardium 
to the diaphragm. 

LATERAL REGIONS. 

AXILLARY regions. 
Boundaries : 

ABOVE, the axilla. 

BELOW, a line on a level with the lower border of the 

mammary region. 
ANTEBIOBLY, a vertical line let fall from the junc- 
tion of the middle with the outer third of the clavicle. 
BOSTEBIOBLY, the anterior or axillary border of 
the scapula. 
Contents : lung-tissue, and the main bronchi deeply 
placed. 

INFRA-AXILLARY regions. 
Boundaries : 

ABOVE, the axillary region. 
BELOW, the margins of the false ribs. 
ANTEBIOBLY, the external boundary of the infra- 
mammary region. 
BOSTEBIOBLY, a line let fall from the inferior 
angle of the scapula (scapular line). 
Contents : 

EITHEB SIDE, lung-tissue. 

BIGHT SIDE, the right lobe of the liver. 

LEFT SIDE, the spleen and part of the stomach. 



22 



PHYSICAL DIAGNOSIS OF THE CHEST. 







Fig. 5.— Posterior surface of the chest. 



POSTERIOR REGIONS. 
SUPRA-SCAPULAR regions. 

Boundaries, those of the supra-spinous fossae. 
Contents : the apices of the lungs. 

SCAPULAR regions. 

Boundaries, those of the infra-spinous fossae. 
Contents : lung-tissue. 

INTER-SCAPULAR region. 
Boundaries : 

EXTERNALLY, the posterior borders of the scapulae. 
The region extends from the level of the second to 
that of the seventh dorsal vertebra. 
Contents : 

BIGHT SIDE, the lung, bronchial glands, and main 
bronchus. 



LANDMARKS OF THE CHEST. 23 

LEFT SIDE, the lung, glands, main bronchus, aorta, 
thoracic duct, and oesophagus. 

INFRA-SCAPULAR regions. 
Boundaries : 

ABOVE, inter-scapular and scapular regions. 
BELOW, the margins of the false ribs. 
POSTERIORLY, the spines of the dorsal vertebrae, 

below the seventh. 
AXTEBIOBLY, the scapular line. 
Contents : 

BIGHT SIDE, the liver, lung, and upper end of the 

kidney. 
LEFT SIDE, the lung and a part of the spleen, kid- 
ney, and intestines. 



LANDMARKS OF THE CHEST. 

The landmarks include the various points, lines, and 
measurements to which reference may be made in showing 
the relation of the deep organs to the surface. 

LINES OF KEFERENCE. 
VERTICAL lines of reference. 

Meso-sternal line, the mid-line of the sternum. 

Sternal lines, right and left, corresponding to the lateral 
margins of the sternum. 

Mammillary (not mammary) lines, right and left, passing 
vertically through the nipples. 

Para-sternal lines, right and left, passing vertically mid- 
way between the mammillary and sternal lines on the 
respective sides. 

Anterior Axillary lines, right and left, passing vertically 
through the points at which the pectoralcs majores leave 
the chest, the arms being at right angles to the body. 

Posterior Axillary lines, right and left, passing vertically 



24 PHYSICAL DIAGNOSIS OF THE CHEST. 

through the points at which the latissimus dorsi leave 

the chest, the arms being at right angles to the body. 
Mid-axillary lines, right and left, midway between the 

anterior and posterior axillary lines. 
Scapular lines, right and left, passing vertically through 

the inferior angles of the scapulae. 
Vertebral line, passing through the spines of the vertebrae. 

HORIZONTAL line of reference. 
Horizontal Nipple Line. 

OBLIQUE line of reference. 

Linea-costo-articularis, drawn from the left sterno- 
clavicular articulation to the free end of the left 
eleventh rib. 



LANDMARKS OF THE LUNGS. 

OUTLINE of the lungs. 

Outline of the Right Lung. 

THE ABEX extends an inch and a half above the first 
rib, and is apt to be a little lower than the apex of 
the left lung. 

THE ANTERIOR BOEDER lies in the meso-sternal 
line from the level of the second to the level of the 
sixth costal cartilage. 

THE INFERIOR BORDER in adults lies as follows, 
in the average position ; on deep inspiration it is de- 
pressed an inch and a half lower; in children it is 
from a half to a full interspace higher ; in the aged 
it is often as much lower : 
IN THE MAMMILLARY LINE at the sixth rib. 
IN THE MID- AXILLARY LINE at the eighth rib. 
IN THE SCAPULAR LINE at the tenth rib. 
Outline of the Left Lung. 

THE ABEX extends one inch and a half to two inches 
above the first rib. 



LANDMARKS OF THE CHEST. 25 

THE ANTEBIOB BOB DEE lies in the meso-gternal 

line from the level of the second to the level of the 

fourth costal cartilage. 
THE INFEBIOB BOB DEB lies (in the average 
position), 

IN THE MESO-STERNAL LINE, at the fourth costal 
cartilage. 

IN THE PARA-STERNAL LINE, at the fifth rib. 

IN THE MAMMILLARY LINE, at the sixth rib. 

IN THE MID- AXILLARY LINE, at the eighth rib. 

IN THE SCAPULAR LINE, at the tenth rib. 
The inferior border of the left lung reaches half to 

three-quarters of an inch lower than the right in the 

mid-axillary and scapular lines. 

FISSURES of the lungs. 

Fissures of the Right Lung. 
THE LONG FISSUBE. 

ITS POSITION : it separates the lower from the mid- 
dle and upper lobes. 
ITS DIRECTION is from above and behind, obliquely 

downward and forward. 
ITS RELATION to the chest is about as follows : 
Near the Vertebral Column it is three inches 
below the apex of the lung (near the inner end 
of the spine of the scapula). 
In the Mid-axillary Line it is about the level of 

the fourth rib. 
Just within the Mammilla ry Line it cuts the 
lower margin of the lung at the sixth rib. 
THE SHOBT OB LESSEB FISSUBE. 

ITS POSITION : it separates the upper from the mid- 
dle lobe. 
ITS DIRECTION is obliquely downward and forward 
from a point near the anterior border of the scapula, 
where it joins the long fissure. 



26 PHYSICAL DIAGNOSIS OF THE CHEST. 

ITS RELATION to the chest- wall is about as follows : 
It lies at first nearly under the third rib, but crosses 
the third intercostal space about the mammillary 
line, and cuts the anterior border of the lung about 
the junction of the fourth costal cartilage with the 
sternum. 
Fissure of the Left Lung. 

THE LONG FISS TIME (the left lung has but one fissure). 
ITS POSITION : it separates the upper from the lower 

lobe. 
ITS DIRECTION is from above and behind, obliquely 

downward and forward. 
ITS RELATION to the chest-wall is as follows (in the 
average position) : 
Near the Vertebral Column it is about three 

inches below the apex of the lung. 
In the Mid-aocillart/ Line it is about the level of 

the fourth rib. 
In the Mammillary Line it cuts the lower mar- 
gin of the lung at the sixth rib. 

LOBES of the 'lungs. 
Anteriorly : 

ON THE MIGHT SIDE, 

THE UPPER LOBE lies above the third intercostal 

space. 
THE MIDDLE LOBE lies below the third interspace, 

reaching to the lower margin of the lung. 
THE LOWER LOBE is practically absent anteriorly. 
ON THE LEFT SIDE, 

THE UPPER LOBE reaches from the apex to the 

lower margin of the lung. 
THE LOWER LOBE is practically absent anteriorly. 
Laterally : 

ON THE MIGHT SIDE, 

THE MIDDLE LOBE is present above the fourth rib. 



LANDMARKS OF THE CHEST. 27 

THE LOWER LOBE reaches from the fourth rib to 
the lower margin of the lung. 
ON THE LEFT SIDE, 

THE UPPER LOBE lies above the fourth rib. 
THE LOWER LOBE reaches from the fourth rib to 
the lower margin of the lung. 
Posteriorly : 

OX BOTH SIDES, 
THE UPPER LOBE practically lies above the spine 

of the scapula. 
THE LOWER LOBE reaches from the spine of the 
scapula to the lower margin of the lung. 

THE TRACHEA. 
Dimensions. 

LENGTH, four and one-half inches. 
CALIBRE, three-fourths to one inch. 



Median Line 



Fig. 6.— Showing divergence of main bronchi. 

Bifurcation, under the middle of the sternum about the 
level of the second costal cartilage, at the level of the 
third dorsal vertebra. The septum or line of divergence 
between the two bronchi is to the left of the median 
line, thus influencing the direction of foreign bodies 
which enter the trachea. 



28 PHYSICAL DIAGNOSIS OF THE CHEST. 

THE PRIMARY BRONCHI. 
Direction. 

THE MIGHT bronchus is nearly horizontal. 

THE LEFT bronchus is oblique. 
Position. 

THE BIGHT lies under the second rib. 

THE LEFT lies under the second intercostal space. 
Length. 

THE BIGHT is about one inch long. 

THE LEFT is nearly two inches long. 
Calibre. 

THE BIGHT bronchus is larger than the left. 




Fig. 7.— Relations of the heart (Holden). 
LANDMARKS OF THE HEAET. 

OUTLINE of the heart. 

The Base nearly corresponds in level with the superior 
margin of the third rib. 



LANDMARKS OF THE CHEST. 29 

The Apex lies under the fifth intercostal space, 

TWO INCHES BELOW the nipple (in the male) and 
HALF AN INCH TO THE BIGHT of the left raam- 
millary line. 

The Right Margin corresponds with a line beginning on 
the third costal cartilage half an inch to the right of 
the right sternal line, curving slightly to the right and 
downward to the end of the sternum. 

The Left Margin corresponds with a line beginning on 
the third costal cartilage an inch to the left of the left 
sternal line, curving to the left and downward to the 
apex beat, but not including the nipple. 

The Lower Margin corresponds nearly with a line join- 
ing the apex and the end of the sternum. 

RELATION of the heart to the lung in front. 

It is Covered by the lung (cardiac dulness) from the 
upper margin of the third to the lower margin of the 
fourth rib, and below the fourth rib between the para- 
sternal line and the left margin of the heart. 

It is Uncovered by the lung (cardiac flatness) in the tri- 
angular or irregularly quadrilateral area bounded on 
the right by the meso-sternal line, on the left and above 
by a line drawn from the fourth costal cartilage to a 
point a little to the right of the apex beat. 

VALVES of the heart. 
Position (Gray). 

SEMILZXAB VALVES. 

THE PULMONIC valve lies behind the left sternal 
line at the level of the third costal cartilage. 

THE AORTIC valve lies close to the left sternal line, 
behind the third intercostal space. 
A ZBICZLO- VEXTBICULAB VAL VES. 

THE TRICUSPID valve lies behind the meso-sternal 
line about the level of the fourth costal cartilage. 



30 PHYSICAL DIAGNOSIS OF THE CHEST. 

THE BICUSPID or mitral valve lies about one inch 
to the left of the sternum behind the third inter- 
costal space. 

LANDMAEKS OF THE AOETA. 

The aorta is most superficial in the right second intercostal 
space at the edge of the sternum. The arch of the aorta 
lies an inch below the inter-clavicular notch. 

LANDMAEKS OF THE INNOMINATE AETEEY. 

Its course may be traced by an oblique line drawn from 
the mid-sternal line at the level of the second costal cartilage 
to the right sterno-clavicular articulation. 

LANDMAEKS OF THE LIVEE. 

RIGHT LOBE of the liver. 
Its Upper Margin lies, 

IN THE MAM3IILLARY LINE, at the fourth in- 
tercostal space. 
IN THE MID-AXILLARY LINE, at the sixth rib. 
IN THE SCAPULAR LINE, at the eighth rib. 
Its Lower Margin lies half an inch below the costal arch, 

in the average healthy adult male. 
Relation of the liver to the lung. 

IT IS COVERED by lung {hepatic dulness), 

IN THE MAMMILLARY LINE, from the fourth inter- 
space to the sixth rib. 
IN THE MID- AXILLARY LINE, from the sixth to the 

eighth rib. 
IN THE SCAPULAR LINE, from the eighth to the 
tenth rib (the lower margin of the lung may be 
depressed an inch and a half on deep inspiration). 
IT IS UNCOVERED by lung (hepatic flatness) from 
these points (sixth, eighth, and tenth ribs) down- 
ward. 



LANDMARKS OF THE CHEST. 31 

LEFT LOBE of the liver. 

Its Upper Margin lies under and against the diaphragm, 
adjoining the heart. 

Its Lower Margin (in the median line) lies about mid- 
way between the end of the appendix sterni and the 
umbilicus. 

Its Left Margin reaches nearly to the left mammillary 
line. 

LANDMARKS OF THE SPLEEX. 
THE SPLEEN IS COMPLETELY SHELTERED beneath 

the ribs, and cannot be felt in health except in rare cases. 

THE OUTLINE of the spleen. 

Its Upper Margin lies under the ninth rib. 

Its Lower Margin lies under the eleventh rib. 

Its Anterior Extremity nearly reaches the linea costo- 

articularis, drawn from the free end of the eleventh rib 

to the left sterno-clavicular articulation. 
Its Posterior Extremity approaches within two-thirds 

of an inch of the body of the tenth dorsal vertebra. 

THE DIRECTION is obliquely backward and upward, the 
long axis corresponding nearly with the direction of the 
tenth rib. 

THE RELATION of the spleen to the lung. 

It is Covered by lung in its posterior and upper third, 
which lies in the infra-scapular region. 

It is Uncovered by lung in its anterior and lower two- 
thirds, which lie chiefly in the infra-axillary region. 

LANDMARKS OF THE VEKTEBR^E. 

THE SEVENTH CERVICAL VERTEBRA, vertebra 
prominens, is readily made out. 

THE TWELFTH DORSAL VERTEBRA may be located 
by reference to the twelfth rib, which may be felt when 
the lumbar muscles are relaxed ; in muscular subjects it 



32 PHYSICAL DIAGNOSIS OF THE CHEST. 

may be located by following the lower margin of the 
trapezius muscle. 

ALL THE SPINES are located by slight friction with the 
finger, reddening the skin over their tips. 

SLIGHT CURVATURE of the vertebral column to the 
right or left exists in right- or left-handed persons. 

LANDMAEKS OF THE BIBS. 

THE SECOND RIB is on a level with the prominence (angle 
of Lewis), more or less marked in all persons, at the junc- 
tion of the first and second pieces of the sternum. 

THE SEVENTH RIB lies at the inferior angle of the scap- 
ula when the arms hang at the sides. 

THE FIFTH RIB is just covered by the convex lower bor- 
der of the pectoral is major. 

THE THIRD COSTO-STERNAL JUNCTION is on a 

level with the body of the sixth dorsal vertebra. 

THE HORIZONTAL NIPPLE LINE cuts the sixth inter- 
costal spaces in the mid-axillary lines. 

THE ELEVENTH AND TWELFTH RIBS can always be 
felt when the abdominal wall is relaxed. 

THE INFERIOR END OF THE STERNUM is on a level 
with the tenth dorsal vertebra. 

LANDMAEKS OF THE SCAPULA. 

The scapula lies over the ribs from the second to the 
seventh. The inner end of the spine of the scapula is 
nearlv on a level with the third dorsal vertebra, main 
bronchus, and beginning of the pulmonary fissures behind. 



METHODS OF PHYSICAL DIAGNOSIS. 33 

METHODS OF PHYSICAL DIAGNOSIS. 

The methods of physical examination are inspection, pal- 
pation, mensuration, percussion, auscultation, and succussion. 

INSPECTION. 
Inspection reveals color, nutrition, size, form, posture, and 
movements. 

COLOR may be due to pigmentation,- or vascularization, or 
both. 
Color dependent upon pigmentation may be 
NORMAL. 

LOCAL, as in the areolae about the nipples, color of 

the eyes and hair. 
GENERAL, as in the Negro, Malayan, Indian, bru- 
nette, and blonde. 
ABNORMAL. 

LOCAL, moles, lentigo, chloasma, the seat of scars, 

leucoderma. 
GENERAL, icterus, argyria, Addison's disease. 
Color dependent upon vascularization. 

XORMAL, erythema, ruddy complexion or the opposite. 
ABNORMAL. 
LOCAL. 

Arterial, congestion, eruptions, etc. 
Jenous, ecchymosis, enlarged superficial veins and 
capillaries. 
GENERAL. 

Arterial, congestion, or its opposite, pallor, chloro- 
sis, anaemia. 
Venous, cyanosis, morbus caeruleus. 
Color dependent upon both vascularization and pigmenta- 
tion is observed in various cachexia*, malignant disease, 
disease of the liver, etc. 

NUTRITION is manifested by the degree of fatty deposits 
or muscular development, as well as by the color. 

3 



34 



PHYSICAL DIAGNOSIS OF THE CHEST. 



SIZE of the chest. 

Normal size of the chest. 

CIRCUMFERENCE of the chest at the level of the 
nipples in man, just above the mammae in women. 
AVERAGE circumference thirty- four inches in men, 

thirty-two in women. 
USUAL EXTREM ES, twenty-eight to forty-four inches. 



Chest- 


MEASUREMENT AS RELATED TO HEIGHT AND 


Weight. 


Height. 


Chest. 


Standard 


20 per cent. 


45 per cent. 






Weight. 


under weight. 


over weight. 


5 feet 


3U 


115 


92 


167 


5 " 1 in. 






34 


120 


96 


174 


5 " 2 " 






35 


125 


100 


181} 


& " 3 " 






36 


130 


104 


188* 


5 " 4 " 






36| 


135 


108 


195 


5 u 5 " 






37 


140 


112 


203 


5 " 6 " 






37J 


143 


114 


207 


5 " 7 " 






38 


145 


116 


210 


5 " 8 " 






38J 


148 


lift* 


215 


5 " 9 " 






39 


155 


124 


224* 


5 " 10 " 






39J 


160 


128 


232 


5 " 11 " 






40J 


165 


132 


239 


6 " . . 






41 


170 


136 


246 



RESPIRATORY EXPANSION, two to seven inches. 
Average of the chest, two inches and a half. 
Usual Extremes, two to four inches. 
SEMI- CIM C UMFERENCE la tera lly . 

THE RIGHT SIDE is usually half an inch larger than 
the left in right-handed persons. 
Abnormal size in 

CIRCUMFERENCE ; this may be disproportionately 
SMALL compared with the vertical diameter of the 
chest, when it is generally associated with flatness 
or hollowness of the upper anterior part of the 
chest, wing-like projection of the scapulae, an acute 
costal angle, and deficient respiratory expansion. 
The circumference is apt to be disproportionately 



METHODS OF PHYSICAL DIAGNOSIS. 35 

LARGE in marked emphysema. 
SEMI-CIRCUMFERENCE ; either side of the chest 
may be 
SMALL compared with the other, as a result of fibroid 
contractions of the lung on that side, following 
pleurisy, pneumonia or collapse. It may be 
LARGE as compared with the other, in case of (exten- 
sive pleuritic effusion or pneumothorax. 
FORM of the chest. 

Normally the chest is a nearly symmetrical, truncated, 
conical pyramid, flattened slightly in its antero-posterior 
diameter. 
Abnormal forms of the chest. 
ASYMMETRICAL forms. 

LOCAL BULGINGS maybe due to irregularities of the 
Chest-wall ; tumors or swellings such as sarcoma, 
abscess, periostitis, or deformities of the bony 
framework. 
Pressure from within, due to the 
Thoracic Organs. 
Circulatory organs. 

Enlargement of the heart in children. 
Hydro- or pneumopericardium, aneurysm. 
Lungs and Mediastinum. 
Tumors or swellings. 

Pleuritic accumulation of gas, fluid, or solids, 
e. g. pneumothorax, serothorax, tumors. 
Abdominal Organs. 

Enlargement of abdominal organs. 
Abnormal accumulation of gas, fluid, or solids, 
encroaching upon the thorax. 
LOCAL DEPRESSIONS, as the retraction of the supra- 
and infra-clavicular regions from contraction of the 
apex of the lungs in phthisis; or the retraction of 
the chest in any region following fibroid induration 
of the lung. 



36 PHYSICAL DIAGNOSIS OF THE CHEST. 

RELATIVELY SYMMETRICAL forms of the ab- 
normal chest. 

THE PIGEON BREAST deformity of the chest occurs 
chiefly in childhood, and is characterized by lateral 
constriction of the thorax, with straightening of 
the true ribs and prominence of the lower end of 
the sternum ; this is a result of rhachitis. 

THE RHACHITIC CHEST is developed in early life; it 
is characterized by lateral retraction of the thoracic 
walls, the anterior surface being broader than in 
the pigeon breast, and the sternum less prominent ; 
the costo-chondral junctions are thickened, pre- 
senting a series of bead-like eminences known as 
the rhachitic rosary. 

THE ALAR CHEST is characterized by wing-like pro- 
jections of the scapulae, usually associated with a 
narrow chest, sloping shoulders, and an acute costal 
angle. It is commonly significant of constitutional 
weakness, which favors the development of pul- 
monary phthisis. 

THE EMPHYSEMATOUS OR BARREL-SHAPED 
CHEST is characterized by roundness of contour, 
the antero-posterior diameter being lengthened, the 
transverse diameter shortened, and the upper end 
of the sternum prominent ; the intercostal spaces 
are wide and full, the shoulders are thrown for- 
ward, the scapulae separated, and the whole pos- 
ture stooping. 

FUNNEL BREAST, characterized by sinking in of the 
lower end of the sternum, is a congenital deformity 
sometimes observed in several branches of the same 
family ; it may be so marked as to interfere seriously 
with respiration. Shoemakers' breast is an acquired 
deformity of similar form, and is caused by the 
pressure of tools against the lower part of the 
sternum. 



METHODS OF PHYSICAL DIAGNOSIS. 37 

HARRISON'S GROOVE is a horizontal line of depres- 
sion along the false ribs, corresponding to the in- 
sertion of the diaphragm ; it is sometimes observed 
in conditions of chronic inspiratory dyspnoea neces- 
sitating powerful action of the diaphragm, especially 
in rhachitic children. 

SPINAL CURVATURES ; the chest may be asymmet- 
rical or symmetrical, deviations being either antero- 
posterior or lateral, or both. These may be due 
either to defective development of the bodies of the 
vertebrae or to caries. 

POSTURE. The position of the body as a whole or in its 
parts is significant as an aid to diagnosis. 
Voluntary posture, as ordered by the examiner. 
NATURAL postures. 

FIXED position, upright, standing, sitting, recumbent. 
CHANGE from the upright posture to recumbency 
may reveal movable organs, fluids or gases, or 
evidence of pain. 
UNNATURAL or specially-arranged postures to facil- 
itate examinations — genu-pectoral, left lateral semi- 
prone, etc. 
Involuntary posture, as assumed by the patient as a re- 
sult of disease. 
POSTURE OF THE BODY AS A WHOLE. 

DROOPING, relaxed, or reclining posture as indicat- 
ing lassitude, debility, helplessness. 
FORWARD, BACKWARD, OR LATERAL inclination 
more or less fixed, as a result of 
Prolonged Habit, or from occupation. 
Partial Destruction of the Pony Support (Pottos 

disease, etc.). 
Muscular Contraction from 

Inflammation of the soft parts, and 
Abnormal Pressures from tumors or enlarged 



38 PHYSICAL DIAGNOSIS OF THE CHEST. 

organs — viz. forward inclination to relieve the 
backward pressure of an aneurysm or other 
tumor against the trachea, marked flexion of 
the body in peritonitis, colic, etc. 
Lesions of the Central or Peripheral Nervous 
System may produce opisthotonos or over-exten- 
sion of the vertebral column from tonic contrac- 
tion of the posterior, cervical, dorsal, and lumbar 
muscles, with associated extension of the thighs 
and extension of the legs in tetanus, spinal menin- 
gitis, hysteroid convulsions. 
RECUMBENCY UPON OR INCLINATION TOWARD 
THE AFFECTED SIDE is common in the first stage 
of pleurisy. 
INABILITY TO LIE ON THE AFFECTED SIDE in 
many cases of pleurisy with effusion, and in case 
of superficial inflammations, or in some cases of 
cardiac disease. 
INABILITY TO LIE DOWN AT ALL in certain cardiac 
and pulmonary diseases interfering with respira- 
tion — viz. asthma. 
POSTURE OF THE BODY IN ITS PARTS. 
FIXED POSITION of the limbs in any position in 

catalepsy. 
LIMBS RELAXED or parts of the body drawn to the 

opposite side in unilateral paralysis. 
LIMBS OR HEAD DRAWN INTO DISTORTED POSI- 
TIONS by muscular or fibroid contractions. 
POSITION OF A LIMB involuntarily corresponds 
to that giving least pain in disease of the 
joints. 
FACIAL EXPRESSION is closely related to posture, 
and depends largely upon the influence of the in- 
tellect, feeling, and will. 

Intellectual, expression of intelligence or imbe- 
cility, etc. 



METHODS OF PHYSICAL DIAGNOSIS. 39 

Emotional, expression of pain, anxiety, fear, grief, 

anger, joy, etc. 
Volitional. 

Voluntary control in the change of expression. 
Involuntary distortion of features as seen in 
paralysis and contraction. 

MOVEMENTS. 

General muscular movements are of interest as being 
normally or abnormally present or absent, as in paralysis 
and chorea, or as eliciting pain. 
GAIT is peculiar in various diseases of the central or 

peripheral organs. 
CONVULSIONS OB TREMORS may be present. 
COUGHING, SNEEZING, SNORING, SIGHING, 
YA WNING, AND HICCO UGH, while visible signs 
as well as symptoms often of disease, are better classed 
with subjective features. Cough as a sign is referred 
to under Auscultation. 
Respiratory movements. 

NORMAL breathing is termed eupneea. The two sides 
of the chest should expand equally, and the upper 
part of the chest should be well filled with each 
inspiration. There is a slight falling in of the inter- 
costal spaces during inspiration, and a corresponding 
shallowness of these during expiration. 
THE RHYTHM or ratio of the inspiratory to the ex- 
piratory act is as six to seven (Gibson), there being 
no pause between them. 
THE TYPES of respiration include costal or superior 
costal breathing as observed in women, inferior 
costal breathing as usually observed in men, ab- 
dominal or diaphragmatic breathing as seen in 
children. 
THE RAPIDITY of normal respiration varies accord- 
ing to 



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40 PHYSICAL DIAGNOSIS OF THE CHEST. 

Intrinsic Conditions* 

Age. 

Under one year, 

One to five 

Five to twenty 

Twenty to twenty-five 

Twenty-five to thirty 

Thirty to fifty 
Physical 

State, posture. 

Activity, general muscular, digestion, etc. 
Mental 

State, temperament. 

Activity, emotional, volitional. 
Extrinsic Conditions. 

Rarity of the Atmosphere, elevation, etc. 
Excessive Heat acting on body-temperature. 
ABNORMAL breathing regards the 
FORM of the chest during respiration. 

Expansion of the chest in abnormal breathing. 
Diminished expansion may be unilateral or bi- 
lateral (vide the conditions and causes of feeble 

respiration). 
Bulging of the intercostal spaces during expira- 
tion is observed in emphysema. 
Retraction of the soft parts of the chest, xiphoid 
process, and false ribs in inspiration occurs in 
croup, paralysis of the vocal cords, and other 
conditions involving obstruction of the upper 
air-passages. . 
RAPIDITY OF ABNORMAL RESPIRATION. 

Abnormally Rapid respiration is termed hy- 
perpnwa. This is observed in most conditions 
causing dyspnoea (vide), notably in the following : 
In Fever, especially in nervous persons, and in 

children. 



METHODS OF PHYSICAL DIAGNOSIS. 41 

In all Conditions Causing- Painful Breathing", 
such as diseases of the pleura, diaphragm, and 
peritoneum, fracture of the ribs, pleurodynia. 
In Diseases Narrowing- the Bronchial Tubes : 

asthma, bronchitis. 
In Conditions Lessening- the Aerating- and Cir- 
culatory Areas of the Lung's. 
Pulmonary Disease : emphysema, oedema, 

pneumonia, etc. 
Pleuritic Affections : air, fluids, or solid 
tumors in the pleural cavity pressing on the 
lungs. 
Abdominal Affections : tumors, swellings, 
or effusion, or gas. 
In Disease of the Heart affecting the pulmonary 

circuit. 
In some Diseases of the Nervous System. 
Abnormally Slow Respiration might well be 
termed hypopncea. This is observed in the 
course of Cheyne-Stokes respiration, and some- 
times in diseases of the brain and meninges ; in 
acute infectious diseases with marked mental 
dulness ; in stenosis of the upper air-passages, 
due to intra-tracheal tumors, foreign bodies, in- 
flammation, compressions from without, and 
paralysis of the abductors of the vocal cords. 
Suspended Respiration is termed apncea, which is 
due to want of a proper stimulus to respiration, 
owing to saturation of the blood with oxygen 
and the presence of a deficient amount of car- 
bonic-acid gas ; it is observed in the course of 
Cheyne-Stokes respiration. It seems to be the 
condition of the foetus in utero. 
Asphyxia literally means absence of the pulse — 
i. e. the almost pulseless condition of suspended 
vitality resulting from lack of oxygen in the 



42 PHYSICAL I) FA GNOSIS OF THE CHEST. 

blood or its saturation with 0O 2 . The stages of 
asphyxia (Landois) are 
Hyperpnoea, lasting about one minute. 
Convulsions, lasting about one minute. 
Exhaustion, lasting about three minutes, during 
which the heart continues to beat, but feebly. 
When the heart ceases to beat recovery is im- 
possible. 
VARIATION IN THE RHYTHM OF RESPIRATION. 
An increase in the number or depth of respirations, 
or both, is the chief characteristic of dyspnoea or 
difficult breathing. 
Dyspnoea. 

Varieties of Dyspnoea. 

Inspiratory dyspnoea : dyspnoea may be 
purely inspiratory, or it may be associated 
with difficult expiration in varying degree; 
it is the result of obstruction to the ingress 
of air into the lung, and is observed in 
croup, compression of the trachea, and 
paralysis of the diaphragm, etc. 
Expiratory dyspnoea, pure, or associated 
with difficult inspiration, is due to obstruc- 
tion to the exit of air from the lung, as is 
typically observed in asthma and emphy- 
sema. 
Mixed expiratory and inspiratory dyspnoea is 
most frequent ; it is observed in many dis- 
eases of the lungs and heart, and in fever. 
Exaggerated dyspnoea, or orthopnea, re- 
quiring the sitting or standing posture and 
the use of the extra muscles of respiration, 
is observed in acute asthma and in advanced 
cardiac disease, etc. 
Cheyne-Stokes Respiration is character- 
ized by a number of shallow respirations 



METHODS OF PHYSICAL DIAGNOSIS. 43 

which become deeper and more dyspnoeic to 
a given point at which there may be a groan, 
and then grow more superficial till they ap- 
parently cease ; after a pause (apnoea) the 
series is repeated, the whole cycle occupying 
from thirty-live seconds to a minute, the 
number of respirations usually being about 
thirty. Daring the pause the pupils are 
contracted and immobile to light, and con- 
sciousness is usually lost. In some cases 
consciousness returns with deep breathing, 
and the pupils dilate and react to light. 
This is normal in animals during hiberna- 
tion ; abnormal in man, due to cerebral or 
medullary disease (meningitis, hemorrhage, 
tumors), uraemia, certain affections of the 
heart, and to opium-poisoning. 
Causes of Dyspnoea. 

Respiratory causes of Dyspxcea may de- 
pend upon 
Insufficient quantity of air supplied to the 
lungs, owing to — 

1. Imperfect respiratory movements, due 

to— 
(a) Paralysis, lesions of the central or 

peripheral nervous system. 
(6) Pain, as in inflammation of the 

pleura and peritoneum, pleurodynia, 

intercostal neuralgia, trichinosis of 

the diaphragm, etc 

(c) Muscular weakness. 

(d) Yielding walls of the chest due to 
rickets and fractures. 

(e) Loss of elasticity of the chest-wall : 
myositis ossificans, scleroderma. 

2. Loss of elasticity of the lungs from 



44 PHYSICAL DIAGNOSIS OF THE CHEST. 

emphysema, pleuritic adhesion, pro- 
longed compression. 

3. Lessened capacity of the chest, due 

to— 

(a) Bony malformations. 

(b) Pressure from thoracic or abdom- 
inal effusion or tumors. 

4. Lessened lumen of the air-passages : 
(a) Extra-mural causes : cicatricial con- 
tractions, pressure of tumors, etc. 

(6) Intra-mural causes : thickening of 
the walls of the air-passages, mus- 
cular spasm, as in bronchitis, asthma, 
and laryngismus stridulus. 

(c) Inter-mural : foreign bodies, secre- 
tions, and false membranes within 
the air-passages. 

5. Diminished surface for circulation and 

interchange of gases in the lung, 
owing to — 

(a) Inflammation of the lungs : pneu- 
monia, fibrosis, tuberculosis. 

(b) Collapse or compression of the lung 
from pressure of air, fluid, or solids : 
tumors, pleuritic effusion, pneumo- 
thorax. 

(c) Destruction of the alveolar capil- 
lary network, as in emphysema. 

Modified quality of the air which is inhaled. 

1. Insufficient density due to heat, high 
altitude, decreased atmospheric pres- 
sure. 

2. Deleterious adulterations : noxious 
gases, etc. 

3. Insufficient oxygen. 
Circulatory causes of Dyspncea include 



METHODS OF PHYSICAL DIAGNOSIS. 45 

Diminished quantity of blood aerated, owing 
to— 

1. Oligemia, after acute hemorrhage. 

2. Pulmonary ischemia, from 

(a) Vis a f route, due to 
Pulmonary disease : emphysema, 

fibrosis, compression, etc. 
Arterial disease. 

Extra-mural : compression, liga- 
tion. 

Intra-mural : inflammation of the 
arterial coats. 

Inter-mural : embolism. 

(b) Vis a tergo may be diminished 

owing to 
Cardiac inefficiency from 
Valvular disease. 
Compression of the heart by peri- 
cardiac or pleuritic effusion. 
Muscular weakness of the heart 
from atrophy, myocarditis, de- 
generation, etc. 
Modified quality of the blood. 

1. Super-heated blood acts on the re- 
spiratory centre, heat-dyspnoea. 

2. Deteriorated blood : pernicious anae- 
mia, fevers, poisons. 

Circulatory Movements. 

VASC ZLA B MO VEMENTS. 
VENOUS movements (pulsations). 
Xortnal Jettons Movements. 

Jugular Presystolic pulsation (slight) is rarely 
visible in health (Yierordt). 
Abnormal Venous Movements, 

Jugular Systolic pulsation occurs in tricuspid 
regurgitation. 



46 PHYSICAL DIAGNOSIS OF THE CHEST. 

Hepatic venous systolic pulsation is sometimes 
visible in marked tricuspid regurgitation. 
ARTERIAL movements (pulsation). 
Normal Arterial Movements. 

Carotid pulsation is frequently visible under the 
angle of the jaw, varying with the degree of 
adiposity and the force and excitation of the 
heart. 
Aortic pulsation is exceptionally visible in the 
supra-sternal region (high position of the 
arch). 
Abnormal Arterial Pulsation. 

Carotid pulsation, when marked, may signify 
hypertrophy of the left ventricle, insufficiency 
of the aortic valve, arterial sclerosis (aortic), 
or aneurysm. 
Aortic pulsation 

In the neck is sometimes due to insufficiency 
of the aortic valve, to aneurysm, or to hy- 
pertrophy of the left ventricle. 
In the right second intercostal space 
pulsation is always abnormal, and is usually 
significant of one of the conditions just 
mentioned. 
Pulmonary arterial pulsation appears to the left 
of the sternum in aneurysm of this artery. 
Pulsation of this artery may sometimes be 
seen in fibrosis of the lung. 
Capillary pulsation (Quincke) may be seen in 
Marked hypertrophy of the left ven- 
tricle, but more often in marked aortic 
insufficiency. The pulsation is observed 
in the bed of the finger-nails, at the fundus 
of the eye, in the mucous membrane of the 
lip under pressure of a glass slide, and also 
in the line of erythema caused by drawing 



METHODS OF PHYSICAL DIAGNOSIS. 17 

the finger-nail with some force over the pa- 
tient's surface. 
CARDIAC MOVEMENT (pulsation). 
APEX BEAT of the heart. 

Cause of the apex beat : The heart changes in 
form, shortening and thickening, in systole, and 
at the same time changes in position, revolving 
on its axis, the apex being projected forward. 
Visibility of the apex beat. 
Normally the visibility varies with the 

Shape of the chest and the width of the 

intercostal spaces ; 
Thickness of the chest-wall from the 
presence of fat, muscle, and mammary 
gland ; 
Posture of the body, the apex being less 

visible in recumbency ; 
Force of the heart's action, as dependent 
upon its innate power and its excitation. 
Abnormally the visibility of the apex beat varies 
greatly. 
Very marked pulsation is usually observed 

in hypertrophy ; 
Slight or absent pulsation is observed in 
Condition* of cardiac weakness from 

1. General debility, or 

2. Local weakness of the heart's muscle, 
dependent upon cardiac atrophy ; cardiac 
degeneration, fatty, fibroid, or amyloid ; 
or cardiac dilatation. 

Interposition of air between the heart and 
ehest-wall: emphysema, pneumothorax, 
pneumo-pericardium ; fluid: pleuritic or 
pericardiac effusion ; so/ids: tumors, 
fibrinous deposit. 

Thickening of the ehest-waU: excessive fat, 



48 PHYSICAL DIAGNOSIS OF THE CHEST. 

scleroderma, oedema, emphysema of the 
chest-wall. 
Displacement of the heart, as by traction 
from behind by fibroid contraction. 
Location of the apex beat. 

Normal Location of the Apex Beat. 

In the adult male it is in the fifth inter- 
costal space, two inches below and one inch 
inside the nipple line. 
Variations from the position in the healthy 
adult male accord with 
Age : in children under ten years the apex 
beat is usually in the fourth intercostal 
space inside or outside the left mammillary 
line ; in old age it is apt to be lower down, 
sometimes in the sixth intercostal space. 
Respiration. Deep inspiration may carry it 

down to the sixth interspace. 
Posture on the 

1. Left side, may carry it to the left of 
the nipple line. 

2. Right side, to the right of the usual 
position. 

Physical exertion or emotion. The apex beat 

may become stronger or broader, or may 

be carried to the left when the individual 

is greatly excited. 

Abnormal Location of the Apex Beat ; it may 

be displaced, 
Upward. 

Pushed up by deformity of the chest- wall ; 
pericardiac effusion (here it is apparently 
so) ; abdominal tympanitis, tumors, and 
ascites ; paralysis of the diaphragm. 

Pulled upward by fibroid contraction of the 
upper lobe of the left lung. 



METHODS OF PHYSICAL DIAGNOSIS. 49 

Upward and to the left. 

Pushed upward and to the left by hyper- 
trophy of the left lobe of the liver or by 
abdominal tumors. 

Pulled by fibroid contractions of the left 
lung. 
Downward and to the left. 

Pushed downward and to the left by de- 
formity of the chest-wall ; large aneurysm 
of the arch of the aorta ; mediastinal tu- 
mors ; right pleuritic effusion or pneumo- 
thorax ; hypertrophy of the left ventricle 
(strong apex beat) ; dilatation of the left 
ventricle (weak apex beat). 

Pulled downward and to the left by fibroid 
contractions of the pleura and lung. 

TO THE RIGHT. 

Pushed to the right by deformity of the chest- 
wall, emphysema of the lungs, left pleuritic 
effusion, or pneumothorax. 
Pulled to the right by fibroid contractions 
of the right lung, or held by pleuritic 
adhesion. 
Located on the rigid side in transposition of 
the thoracic organs (a rare condition). 
PRECORDIAL PULSATION is observed together with 
the apex beat, 
In Valvular Disease frequently ; in cardiac irrita- 
bility, especially in thin or young persons ; in 
adhesive pleurisy with mediastinal pericarditis, 
here there is usually a systolic drawing in of 
several intercostal spaces. 
In Infiltration of the Lung lying in front of the 

heart. 
In Empyema Pnlsans, which may occur when 
pus in the pleural cavity lies in front of the 



50 PHYSICAL DIAGNOSIS OF THE CHEST. 

heart, the cardiac movements being communi- 
cated to the fluid. It is probably favored by 
paresis of the intercostal muscles, high tension 
in the fluid and a powerful heart. 
EPIGASTRIC PULSATION. 

Hypertrophy of the Might Ventricle, especially 
if accompanied by pulmonary emphysema, fre- 
quently causes a systolic pulsation or trembling 
of the epigastrium. 

Pulsation of the Normal Heart may be trans- 
mitted to the epigastrium through an hyper- 
trophied left lobe of the liver. 

Pulsation of the Normal Aorta may be seen in 
the epigastrium in thin persons, especially when 
the stomach is empty. 

Pulsation of ah Abdominal Aneurysm of the 
aorta may be visible in the epigastrium. 

Venous Hepatic Pulsation, observed in the epi- 
gastrium, may occur in marked tricuspid in- 
sufficiency (rare). 

PALPATION. 

Palpation is the method of physical examination by the 
sense of touch, and it confirms much of what has been ob- 
tained by inspection ; it reveals 

SIZE, SHAPE, contour, roughness, etc. 
CONSISTENCE, fluctuation, 

MOISTURE AND HEAT; and elicits 

PAIN. 
Area. 

LOCALIZED, as in intercostal neuralgia (Valleix's 

three tender points). 
GENERAL sensitiveness, hyperesthesia. 



METHODS OF PHYSICAL DIAGNOSIS. 51 

Depth. 

SUPERFICIAL. 

SKIN, inflammation. 
MUSCLE, pleurodynia. 

FRACTURE OF RIBS (crepitus, tenderness, disloca- 
tion). 
DEEP-SEATED. 
PLEURA. 

MOVEMENTS. 
Muscular. 
Respiratory. 
Circulatory. 

CARDIAC MOVEMENTS, apex beat, precordial pul- 
sation, etc. (vide under inspection). 
EXTENT. 
Localized. 
Diffused. 
CHARACTER. 
Intensity. 
Rhythm. 
VEX O IS MOVEMENTS. 
ARTERIAL MOVEMENTS upon palpation 
AORTIC dilating pulsation of aneurysm, etc. 
CAROTID pulse. 
RADIAL pulse. 

Factors in the Production of the Pulse. 
Force of the Heart's Beat. 
Elasticity of the Large Vessels. 
Resistance at the Valvular Orifices of the 

heart. 
Resistance in the Arterioles and capillaries. 
Volume of the Blood. 
Characteristics of the Pulse, as regards 
Quality of the pulse. 

Degree of tension of the pulse. 



52 PHYSICAL DIAGNOSIS OF THE CHEST. 

Increased or high tension makes the incom- 
pressible or hard pulse. Tension is 
increased during inspiration, being 
highest : 

1. At the beginning of expiration, except 
in pulsus paradoxicus. 

2. By accelerated action of the heart. 

3. By stimulation of the vaso constrictors, 
as by the action of cold, electricity, and 
certain drugs. 

4. By diminished outflow of blood at the 
periphery. 

5. By disease of the vessel walls : athero- 
ma, sclerosis, old age ; drugs — e. g. 
lead-poisoning. 

6. By compression of the large arterial 
trunks, ligation, or pressure. 

7. By impeded venous flow, as in preg- 
nancy, constipation, chronic bronchitis, 
emphysema, nephritis, etc. 

Decreased or low tension makes the com- 
pressible or soft pulse ; tension is de- 
creased during expiration, being lowest : 

1. At the beginning of inspiration, ex- 
cept in pulsus paradoxicus. 

2. After a hemorrhage. 

3. By stoppage of the heart. 

4. In elevated parts of the body. 

5. By stimulation of the vaso dilators, 
action of drugs. 

Degree of fulness of the artery or volume 
of the pulse. 
Increased volume of the pulse makes the 
large or full pulse. This is seen in car- 
diac hypertrophy, plethora, early stage of 
chronic nephritis. 



METHODS OF PHYSICAL DIAGNOSIS. 53 

Decreased volume of the pulse makes the 
small empty pulse as seen in general 
weakness from wasting disease, cardiac 
weakness, cardiac valvular lesions, aortic 
stenosis, mitral stenosis, or marked in- 
sufficiency without compensation. 
Alternate increase and decrease of the volume 
of the pulse is observed in aortic insuf- 
ficiency, giving the collapsing or water- 
hammer pulse of Corrigan. 
Force of each pulse-wave depends chiefly upon 
the energy of the cardiac systole, and also 
upon the amount of vascular tone. 
Increased force of each pulse-wave, making 
the strong pulse, occurs with increased car- 
diac energy and vascular tone. 
Decreased Force of each pulse- wave, making 
the weak pulse, is the result of cardiac debility. 
Duration of each pulse-wave depends upon the 
dilatation of the artery by the blood-current, 
and its contraction during the passage of 
the blood into the capillaries. 
Prolonged duration of each pulse- wave, 
giving the slow or sluggish pulse, occurs in 
all diseases producing contraction of the 
smaller arteries, as nephritis, artero-sclerosis, 
angina pectoris. 
Shortened duration of each pulse-wave, 
giving the active, quick pulse, is present in 
all diseases and conditions giving relaxed 
arteries, as in febrile affections and in aortic 
regurgitation. 
Rhythm of the Pulse. 
Varieties of rhythm. 

Irregular pulse, as respects time, rate, and 
volume. 



54 PHYSICAL DIAGNOSIS OF THE CHEST. 

1. Irregular in time : varying length of 
successive intervals between beats, 
either rhythmical or arhythmical. Ir- 
regularity in rate may be manifested by 
change in rapidity from fast to slow or 
vice versa. 

2. Irregular in volume : varying strength 
or fullness of successive beats. 

(a) Pulsus bigeminus : beats occurring 
in pairs, with intervals between each 
pair, the second beat of each pair 
being weaker than the first. 

(b) Dicrotic pulse : characterized by a 
double beat — i. e.\ a large beat fol- 
lowed by a small after-beat, occurring 
with each cardiac systole ; it is a weak 
pulse of low tension. It is obtained 
in fever patients and in some condi- 
tions of great exhaustion. 

(c) Pulsus trigeminus : groups of three 
beats, the groups being separated by 
intervals. 

(d) Intermittent pulse : here a beat is 
dropped out or is abortive, cardiac 
systole not being strong enough to 
send through the arteries a wave of 
sufficient size to be felt at the wrist, 

(e) Pulsus paradoxicus : normally the 
tension of the pulse is increased 
during inspiration, but in pulsus 
paradoxicus it is decreased during 
inspiration, the pulse being very 
small or even absent at that time. 
It depends upon diminished lumen 
of the aorta, and notably occurs in 
mediastinal pericarditis, concretii 



METHODS OF PHYSICAL DIAGNOSIS. 55 

pericardii, and with large pleuritic 

effusion. 

(/) Irregularity or incoordination of 

the two radial pulses is sometimes 

observed in aortic aneurysm or 

aneurysm of the pulmonary artery. 

Causes of broken rhythm of the pulse. 

General causes of broken rhythm. 

1. Nervous ) . . ,. 

9. C 1 f V I actlon °* drugs or disease. 

Local causes of broken rhythm. 

1. Reflex, dyspepsia, etc. 

2. Circulatory, diminished blood pressure 
in the arteries, as in anaemia. 

3. Cardiac weakness from 

(a) Degeneration, atrophy, etc. 
(6) Mechanical interference with its 
action ; 
Acting within the cardiac apparatus, 
due to valvular disease, pericardiac 
effusion. 
Acting from outside the heart : pleu- 
ritic effusion, distended stomach, 
hepatic enlargement, tumors, de- 
formities of the chest. 
Frequency of the Pulse, rate or number of 
beats. 
The average pulse rate in healthy adult 
males is seventy-one beats ; in females, 
eighty per minute ; the pulse is relatively 
more rapid also in infancy, in small persons, 
in the upright position, in high altitudes, in 
late periods of the day, after meals, during 
emotional excitement, intellectual exercise, 
or muscular exertion. 
The slow pulse, bradycardia, is character- 



56 PHYSICAL DIAGNOSIS OF THE CHEST. 

ized by a rate of sixty beats or less per 
minute ; it has been observed as ldw as 
fifteen beats. It is 
Normal in 

1. Certain persons, habitually, apparently 
inherited. 

2. Women immediately after child-birth. 

3. Old age. 
Abnormal. 

1. Symptomatic in 

(a) General diseases and conditions at- 
tended by great exhaustion, e. g. con- 
valescence from acute fevers, typhoid, 
diphtheria, pneumonia, and in dia- 
betes and anaemia. 
(6) Digestive tract : aggravated dys- 
pepsia, gastric ulcer, cancer of the 
oesophagus. 

(c) Urinary tract : uraemia. 

(d) Cardiac coronary sclerosis, myocar- 
dial degeneration, fatty, fibroid, etc., 
aortic stenosis. 

(e) Nervous system. 

Central diseases with gross lesions, 
as in early stage of meningitis, 
apoplexy, tumors of the cerebrum, 
injuries to the cervical cord. 

Peripheral, pressure upon the vagus 
by tumors, etc. 

Neuroses, so-called idiopathic disease 
of the nervous system — epilepsy, 
hysteria in certain cases, mania, 
general paresis, following fright. 

Toxic: tea, coffee, lead, uric acid 
(uraemia), bile (jaundice). 
The rapid pulse, tachycardia, is character- 



METHODS OF PHYSICAL DIAGNOSIS. 57 

ized by a rate of eighty-five beats or more 
per minute; it lias been observed as 
high as two hundred and fifty beats in 
adults. 
Normally, the pulse is rapid in certain healthy 
adults habitually, and in certain indi- 
viduals who are able voluntarily to in- 
crease the rate of the heart ; in women at 
gestation : and in children as follows : 
Infants, 130 to 150. 

One year old, 120 to 130. 
Two years old, 105. 
Three years old, 100. 
Five years old, 90 to 94. 

Variations from emotions and phys- 
ical exercise, etc., vide the average 
pulse. 
Abnormally rapid pulse may be 
1. Symptomatic, arising from 

(a) Undue irritation of the nervous 
system, as related to 
Age : young rapidly-growing w r eak 

persons. 
Sex : women usually at establishment 
of menstruation and the meno- 
pause, especially when anaemic and 
chlorotic. 
Habits: venereal excess, masturba- 
tion. 
Toxic : tobacco, alcohol, tea, coffee. 
Fatigue : physical or mental. 
Fever. 
(6) Lesions of the cardiac nervous 
mechanism. 
Central : bulbar disease impairing 
the function of the vagus, tumors 



58 PHYSICAL DIAGNOSIS OF THE CHEST. 

or swellings, softening in the 
medulla or cord, hemorrhage. 
Peripheral : tumors or swellings 
pressing upon the vagus, neuritis. 
Neuroses. 

Exophthalmic goitre. 

Epilepsy, hysteria, irritable heart 

of soldiers. 
Neurasthenia. 
2. Reflex. 

(a) Circulatory : lesions of the heart or 

vessels. 
(6) Respiratory : nasal growths and 
hypertrophies, pharyngeal and laryn- 
geal disorders. 

(c) Gastro-intestinal : dyspepsia, intes- 
tinal worms in children. 

(d) Genito-urinary : ovarian and uter- 
ine disease, nephritis, phimosis. 

Fremitus is a trembling felt by the hand on examination. 
It has been termed fremissement cataire from its like- 
ness to the vibration felt upon the back of a purring 
cat. 

CIRCULATORY FREMITUS or thrill is due to 
vibrations originating within the heart or great ves- 
sels, and it includes : 

ANEURYSMAL or VASCULAR FREMITUS, sometimes 
felt over large superficial aneurysms, and occa- 
sionally over the carotids in valvular disease of 
the heart, and over the jugular veins in tricuspid 
insufficiency ; also, 
ENDOCARDIAL or CARDIAC FREMITUS, not infre- 
quently obtained, upon palpation of the prsecordia, 
in certain valvular lesions. 

Causes of Cardiac Fremitus : like certain cardiac 
murmurs it may be due to the whirling of the 



METHODS OF PHYSICAL DIAGNOSIS. 59 

blood-stream against a roughened surface or past 
a constriction. 
Frequency of Cardiac Fremitus. 

It generally occurs with loud cardiac murmurs, 
but comparatively few murmurs are accom- 
panied by a thrill. 
It is most common with mitral obstruction 

(presystolic) and aortic obstruction (systolic). 
It is more rare with aortic regurgitation (dias- 
tolic), mitral regurgitation (systolic). 
It is very rare with lesions of the right heart. 
Location of Cardiac Fremitus. 

It is generally felt best when the murmur is 
heard loudest — e. g., just above the apex in 
mitral obstruction ; in the aortic area in aortic 
obstruction and atheroma ; over the jugulars 
in case of constriction of these vessels from 
pressure, as in enlargement of the thyroid gland ; 
over the carotids (systolic) in aortic regurgita- 
tion from the sudden filling of the relatively 
empty vessels. 
Intensity of Cardiac Fremitus. 

It is apt to be, like Murmurs, increased by ex- 
ertion. 
It may disappear in cardiac weakness, and re- 
turn with reviving strength or upon excitement. 
FBICTIOX FREMITUS is a rubbing or grating sen- 
sation felt by the hand in palpation over a part where 
two roughened, inflamed, serous surfaces are moving 
upon each other, as in the first stage of pleurisy, oc- 
casionally in pericarditis, and rarely in peritonitis. 
KHONCHAL, BROXCHTAL, or rale FREMITUS 
is caused by the passage of air through fluid in the 
trachea and larger bronchi during respiration ; the 
vibrations produced are sometimes so marked as to 
be felt by the hand upon palpation. 



60 PHYSICAL DIAGNOSIS OF THE CHEST. 

CAVERNOUS FRE3IITUS : this may sometimes be 
felt over superficial cavities in the lung, owing to the 
vibration of fluid within them. 

VOCAL FREMITUS, variously termed voice frem- 
itus, vocal vibration or pectoral fremitus, is a trem- 
bling felt by the hand when placed upon the chest of 
a person who is speaking aloud (tussive or cough 
fremitus is of the same nature). 
INTENSITY OF VOCAL FREMITUS. 
Increased or marked vocal fremitus. 
Normal, is found with 

LOW PITCHED VOICES, 

Strong voices ; near to the 

Larynx ; over the 

Trachea and 

Great bronchi ; it is more marked over the 

Eight apex of the lung than over the left, 

owing to the size and direction of the right 

bronchus ; it is more marked over 
Thin chests from the absence of muscle or 

fat. 
Abnormal, increased vocal fremitus is found : 
Over consolidation of the parenchyma of 

the lung, when the bronchial tubes, of large 

and medium size, are patulous, as obtains in 

phthisis and pneumonia ; 
Over compressed or collapsed lung above 

the level of the effusion ; . 
Over a cavity near the surface, with dense 

walls and a free opening into a large 

bronchus. 
Diminished or Suppressed vocal fremitus. 
Normal, vocal fremitus is weak or absent with 
High pitched voices ; 
Weak voices ; 
Women, over lower half of chest ; 



METHODS OF PHYSICAL DIAGNOSIS. 61 

Children, over the whole client ; and at a 

Distance from the larynx and large 
bronchi ; over 

Thick chest- walls from excess of fat, mus- 
cle, or mammary gland. 
Abnormal, diminished vocal fremitus is due to 

Interposition of 

Fluid, as in hydrothorax, pleurisy with effu- 
sion, etc. ; 
^4//-, as in emphysema, pneumothorax; 
Solids, as in adherent and markedly thick- 
ened pleura, large solid tumor. 

Obstruction of the large bronchial 
tubes from the presence of a foreign body, 
or compression by a tumor or stricture. 

MENSURATION. 

Measurement determines size and the symmetry or asym- 
metry of the chest ; in the latter case it is instituted from the 
middle point behind to the middle point in front. 

PEKCUSSION. 

Percussion is the art of eliciting sounds by striking the 
body. 

METHODS of percussion. 

Immediate, striking directly upon the part; this method 

is of comparatively little use. 
Mediate, striking upon an intermediate object held against 

the part. 

INSTRUMENTS, in mediate percussion (varieties). 
Hammer, plexor or plessor. 

Pleximeter, or plessimeter, the medium upon which the 
hammer strikes. 



62 PHYSICAL DIAGNOSIS OF THE CHEST. 

THE NATURAL and most useful instruments are the 
middle or index fingers of one hand, serving as plexor, 
and one or more fingers of the other hand, as pleximeter. 

ARTIFICIALLY, they may be made of hard rubber, 
wood, etc. 

RULES FOR PERCUSSION. 
The Patient. 

THE SURFACE should be bare of clothing. 
THE LIMBS symmetrical, the same position being 
maintained in the examination of the two sides. 
TO EXAMINE THE FRONT of the chest the arms 

should be at the sides. 
TO EXAMINE THE BACK the arms should be folded 

in front. 
TO EXAMINE THE SIDES the arms should be folded 
above the head. 
POSITION OF THE BODY. 

EASE OF POSITION, to avoid discomfort and to in- 
sure like muscular tension on the two sides. 
POSTURE: the erect, recumbent, or sitting posture, 
or all these may be required, as in determining 
change of position of solid organs or of the level 
of fluids ; recumbency must be maintained if there 
is danger of heart failure. 
The Examiner should maintain a position symmetrical 
with regard to the patient, the ear being at the same 
relative distance from the points percussed. 
The Instruments (their use). 

THE FLEXIMETER should be applied 

WITH FIRMNESS, to avoid a cushion of air beneath 
it ; the firmness of pressure should be uniform at 
all points of percussion. 
PARALLEL TO THE RIBS, upon or between them. 
OVER SYMMETRICAL POSITIONS on the two sides 
of the chest for comparison. 



METHODS OF PHYSICAL DIAGNOSIS. 63 

THE FLEXOR and its use : 

THE STROKE should be made WITH THE ENDS OF 
THE FINGERS rather than with their pulps. 

THE STROKE SHOULD BE MADE PERPENDICU- 
LARLY to the surface. 

THE STROKE should be REBOUNDING, in using the 
hand the motion should be from the wrist. 

THE STROKES should be MODERATELY RAPID in 
succession. 

THE STROKE should be made with MODERATE 
FORCE, never causing pain, but more forcible for 
sounding deep-seated organs than for superficial. 

THE TWO SIDES SHOULD BE PERCUSSED IN 
LIKE STAGES OF RESPIRATION, preferably at 
the end of expiration. 

PERCUSSION SOUNDS. 

The Elements of Sound in percussion. 

Q UALITY, the characteristic property or chief attribute 
which distinguishes one sound from another — e. g. 
full, empty, shallow, clear, soft, hard, toneless, dead, 
"thigh sound/' 
INTENSITY, the quantity or loudness, largely govern- 
ing the distance at which a sound can be heard ; 
varying with 
THE FORCE OF THE BLOW. 
THE VOLUME OF AIR under the part. 
THETHINNESS AND ELASTICITY OF THE CHEST- 
WALL. 
DURATIOX, the length of time a sound can be 

heard. 
TITCH, the degree of elevation in the musical scale. 
ITS RELATION to duration and intensity, the lower 
the pitch the longer the duration, and the greater 
the intensity, and per contra. 
THE FACTORS IN ITS PRODUCTION. 



64 PHYSICAL DIAGNOSIS OF THE CHEST. 

The Larger the Cavities (containing gas) in the 

part, the lower the pitch, and per contra. 
The Greater the Tension of the Inclosing Wall, 

the higher the pitch, and per contra. 
Proximity of Solid Bodies elevates the pitch. 
The Larger the Opening in a cavity, the higher 
the pitch. 
The Varieties of Percussion Sounds. 

NORMAL PULMONARY OR VESICULAR 
RESONANCE or lung sound. 
LOCATION, over those parts of the healthy lung 
which do not overlap the heart, liver, or spleen, 
and which are not covered by the scapulae (vide the 
landmarks). The resonance obtained over the lung 
which overlaps these organs, while normal vesicular, 
is relatively less resonant, and hence properly 
termed dulness. Resonance is less intense and 
higher in pitch over the right apex than over the left. 
CAUSE of the normal vesicular resonance ; it is prob- 
ably due to the combined vibration of the walls of 
the chest, alveoli, and bronchi and the air con- 
tained within them, the resonance of the deeper 
parts being modified by the thickness of the fleshy 
parts and by the elasticity of the bony elements. 
CHARACTER of normal vesicular resonance. 
Quality, soft, clear, full, resonant, vesicular. 
Pitch, low. 
Intensity, great. 
Duration, long, 
VARIATIONS IN CHARACTER. 
In the Same Individual. 

In a Given Location vesicular resonance varies 

with the degree of respiratory expansion. 
In Different Locations it varies according to 
the size or amount of lung under the part and 
the thickness of the chest-w T all. 



METHODS OF PHYSICAL DIAGNOSIS. 65 

In Different Individuals it varies according to 
the same factors. 
EXAGGEBATED PULMOXABY BESOXAXCE. 

LOCATION. 

Xortnal, over both lungs in children. 
Abnormal. 

Over both Lungs in marked anaemia, in em- 
physema (the resonance present in this disease 
has also been termed by Flint vesiculotym- 
panitic). 
Over One Lung* when the other is partially or 
wholly crippled by consolidation, compres- 
sion, etc. 
Over Sound Parts of a crippled lung. 
CAUSE, the lung is over-distended with air, either 
functionally, or from organic trouble as in em- 
physema. 
CHARACTER : this is like that of vesicular resonance, 
except for increase of intensity and duration and 
slightly lower pitch. 
VARIATIONS IN CHARACTER accord with the 
amount of air in the part, within reasonable limits. 
BOXE BESOXAXCE. 

LOCATION, over the sternum and clavicle, and to a 

slight extent over the ribs. 
CHARACTER. 

Quality, non-tympanitic, resonant, ringing. 
Pitch, higher than that of vesicular resonance. 
Intensity, less than that of vesicular resonance. 
Duration, shorter than that of vesicular resonance. 
DULXESS, diminished resonance. Tt includes vesic- 
ular and tympanitic dulness. 
LOCATION. 

Xormal Vesicular Dulness is obtained where the 
lung overlaps the heart, liver, and spleen and 
underlies the scapula). Normal tympanitic dul- 

5 



66 PHYSICAL DIAGNOSIS OF THE CHEST. 

ness is found over the lower part of the liver, 
heart, and spleen when the stomach and colon 
are distended with gas. 
Abnormal Vesicular Dulness is obtained over 
Thickening 1 of the Chest-wall from oedema, 

tumor, or inflammatory swelling. 
Interposition, between the lung and chest-wall, 
of solids or fluids ; a moderately thick layer 
of inflammatory lymph on the pleural surface ; 
a moderate amount of pleuritic effusion, in- 
flammatory or non-inflammatory ; extra-pul- 
monary tumors of small size. 
Consolidation of the Lung*, moderate in amount: 
pneumonia, tuberculosis, syphilis, new growths, 
oedema, pulmonary hemorrhage, collapse of 
lung. 
CAUSE, less air or relatively more solids beneath the 

part than in normal lung. 
CHARACTER. 

Quality, harder, emptier, less clear, less vesicular 

than normal pulmonary vesicular resonance. 
Pitch, higher. 
Intensity, less. 
Duration, shorter. 
VARIATIONS, in character in different individuals 
and in different localities, accord with the relative 
amount of air or solids, approaching the character 
of pure pulmonary resonance on the one hand and 
flatness upon the other. 
FLATNESS. 
LOCATION. 

Normal, over those organs or parts containing no 
air, hence over that portion of the heart, liver, 
spleen, and kidneys uncovered by lung. 
Abnormal, over the chest when there is an exag- 
geration of any of those morbid conditions which 



METHODS OF PHYSICAL DIAGNOSIS. 67 

in a slight degree produce dulness : pleurisy with 
effusion, emphysema, hydro-thorax, etc. 
CAUSE, entire absence of air or gas in and for some 
distance beneath the organ under the part percussed. 
CHARACTER. 

Quality, hard, empty, muffled, non-resonant, the 

" thigh sound." 
Pitch, very high, highest of all percussion notes. 
Duration, very short. 
NO VARIATIONS OF ITS CHARACTER, as such, 
occur ; it may be modified by tympanitic resonance, 
where hollow gas-containing organs like the stom- 
ach or colon underlie a solid organ like the liver ; 
it is then termed tympanitic dulness, really a modi- 
fication of tympany. 
TYMPANITIC RESONANCE or tympany. 
LOCATION. 

Normal, where the stomach or colon, distended 
with gas, underlies the infra-mammary, infra- 
axillary, and infra-scapular regions, and some- 
times over the lower part of the mammary and 
inferior sternal regions ; also over the trachea. 
Abnormal. 

Over a part of the chest when Gas is present 

in the Pleural Sac, pneumo-thorax. 
Over a Pulmonary Air-containing" Cavity of 

large size, phthisis, abscess. 
Complete Solidification of a Part of the upper 
lobe of the lung, tympany being obtained from 
the trachea beneath (" tracheal tone" of Wil- 
liams), second stage of pneumonia, phthisis. 
Bronchiectasis with surrounding solidification, 

interstitial pneumonia. 
Conduction of Stomach Resonance high up 
on the left side, when the lower lobe of the 
left lung is solidified. 



68 PHYSICAL DIAGNOSIS OF THE CHEST. 

CAUSE, percussion over a hollow gas-containing or- 
gan or cavity, the walls of which are more or less 
thin and tense. 
CHARACTER. 

Quality, non-vesicular, resonant, ringing, but 

harder than vesicular resonance. 
Pitch, higher than vesicular resonance, variable. 
Intensity and duration variable. 
VARIETIES OF TYMPANY. 

Closed Tympany is the sound obtained by percus- 
sion over a cavity filled with gas, and not com- 
municating freely by an opening with the ex- 
ternal air — e. g., the stomach and colon. It is 
obtained also in some cases of pneumothorax. 
Open Tympany includes amphoric and cracked- 
metal resonance. 
Amphoric Resonance is obtained over a cavity 
with a large opening, as in percussion of the 
cheeks with the mouth open. 
Location. 

Normal over the trachea, and sometimes 
over the upper part of the chest in chil- 
dren. 
Abnormal , abscess or tubercular cavity com- 
municating with a large bronchus. 
Cause, percussion over a moderate sized gas- 
containing cavity with rigid, non-collapsing 
walls and free communication by a large 
opening ; the examiner's ear or the mouth 
of the stethoscope should be near the 
patient's open mouth. 
Character, its quality is tympanitic but pe- 
culiarly ringing and hollow like the sound 
produced by blowing across the mouth of a 
bottle ; its pitch is higher than vesicular res- 
onance, but varies with the size of the cavity 



METHODS OF PHYSICAL DIAGNOSIS. 69 

and of the opening, and the condition of the 

adjacent lung. Its intensity and duration 

are variable. 
Change ra the Character of amphoric 
resonance. 

Wintrich's change of sound only occurs over 
a cavity which freely communicates with 
a bronchus ; a louder, more amphoric, and 
higher-pitched note is produced over a 
cavity when the mouth is open, especially 
with the tongue protruding. The note 
with the mouth closed may be dull but 
slightly tympanitic. 

Williams' trachea! tone, or change of sound, 
so called, is the tympanitic note obtained 
by percussion over the trachea, its change 
in character being similar to that in Wint- 
rich's change of sound. 

Interrupted Wintrieh's change of sound (Ger- 
hardt, Moritz). This differs from the 
former in that the change is marked in 
some positions of the body, in others in- 
distinct or absent owing to the closure of 
the opening by the secretions within the 
cavity. 

Gerhardfs change of sound. A tympanitic 
sound, whether open or closed, may change 
in pitch with change in posture. This 
may be due to the change in the tension 
of the chest-wall and that of the cavity, 
and to the change in location of fluids 
within the cavity. 

Friedreich's, or the respiratory change of 
sound. A tympanitic note over the lung, 
or over a cavity within it, is higher in 
pitch at the end of deep inspiration than 



70 PHYSICAL DIAGNOSIS OF THE CHEST. 

in expiration, due probably to the higher 
tension. 
Cracked-metal Resonance is a form of open 
tympany, and may be imitated by striking 
upon the knee with the hands loosely clasped 
palm to palm. 
Location and Cause. 
Normal. 

1. If the chest be covered with much 
hair, under percussion. 

2. If the pleximeter be loosely applied. 

3. Sometimes it is obtained over the upper 
part of the chest of children, especially 
when crying. 

4. Sometimes in adults when singing a 
prolonged note. 

Abnormal. 

1. Over some air-containing pulmonary 
cavities communicating with a bronchus 
by a small opening ; percussion should 
be firm, and during expiration, the 
patient's mouth being open. 

2. Occasionally in pleurisy, over the lung 
above the effusion ; sometimes in the 
engorgement stage of pneumonia. 

3. When an opening exists through the 
chest- wall into the pleural sac. 

AUSCULTATION. 

METHODS of auscultation. 
Immediate or direct. 
Mediate or indirect. 

INSTRUMENTS of mediate auscultation, the stethoscope. 
Varieties. 

UNIA UKAL, hollow and solid. 



METHODS OF PHYSICAL DIAGNOSIS. 71 

BIN A URAL, Knight's, Camman's, Dennison's, Alli- 
son's differential, Cor win's multiplex. 
Objections to the stethoscope. 

IT HAS A SPECIAL RING or roaring sound like a 
shell. 

OFTEN POORLY MADE. 

FRIGHTENS CHILDREN. 

NOT ALWAYS AT HAND. 
Advantages of the stethoscope. 

SHUTS OUT OUTSIDE SOUNDS. 

CONCENTRATES and circumscribes sounds. 

INTENSIFIES sounds. 

CERTAIN PARTS OF THE CHEST ARE INAC- 
CESSIBLE to the unaided ear. 

IT IS SOMETIMES INDELICATE to apply the 
ear directly to the chest. 

IT IS SOMETIMES UNPLEASANT and may be 
DANGEROUS to apply the ear to the chest. 
RULES for auscultation. 

The Patient should have regard to 

SYMMETRY, immobility, and ease of position. 

THE CHEST SHOULD BE BARE for mediate aus- 
cultation, and should have a single layer of thin soft 
covering for immediate auscultation. 
The Examiner should have 

THE HEAD on a plane higher than the body to pre- 
vent congestion of the auditory apparatus ; 

THE ATTENTION concentrated upon one sound or 
set of sounds at a time. 
The Instruments. 

THE EAR-PIECE should fit the external meatus ac- 
curately and point in the same direction as the canal, 
downward and forward. 

THE TUBES should be, in lumen, the size of the ex- 
ternal auditory canal ; it is of no advantage to have 
them larger. 



72 PHYSICAL DIAGNOSIS OF THE CHEST. 

THE LAB GEM CHEST-PIECE should not exceed 
one and one-fourth inch in diameter at the distal end. 
It is designed for the lung sounds. 

THE SMALLER CHEST-PIECE is especially de- 
signed for the sounds of the heart and vessels. But 
it answers very well for auscultation of the lungs. 

THE EN TIME LENGTH of the instrument from ear- 
piece to chest-piece should not exceed about twenty-two 
inches (vide cut of simple compact stethoscope which 
the author has found a most satisfactory combination). 
The Act of auscultation. 

THE BOOM should be quiet. 

THE EAB OF THE STETHOSCOPE should be 
firmly applied to the chest. 

THEBE SHOULD BE NO FBICTION between 
parts of the instrument ; between the chest and the 
instrument; between the hand and the instrument; 
between the hand and the chest ; between the hand 
and the clothing ; between the chest and the clothing. 

COBBESPONDING PABTS OF THE CHEST 
should be compared, and in like stages of respiration. 

THE ENTIBE CHEST should be examined. 

SOUNDS HEARD upon auscultation. 
The Elements of sound. 
QUALITY, ~\ 
PITCH, I . 

T>TTT? A TTON I C P ercusslon SOUnds. 

INTENSITY, J 

BHYTHM is the relation of sounds to each other, as 
that of inspiration to expiration, or the relation of the 
first and second sounds of the heart. 
Varieties of Sounds upon auscultation. 
PULMONABY sounds. 

RESPIRATORY sounds vary in kind, intensity, and 
rhythm. 



METHODS OF PHYSICAL DIAGNOSIS. 73 

Kinds or Varieties of Respiratory Sound. 

Normal Vesicular Breathing 1 (persons should 
breathe more forcibly than usual, but with 
the same rhythm). 
Locality : it is heard over the parenchyma 
of the luiiff away from the main bronchi ; 
best in the infra-scapular regions. 
Cause of the vesicular sound (opinion varies). 
It may be produced at the glottis, and mod- 
ified by conduction through the spongy 
tissue of the lung. 
It may be due to the entrance of air into the 

alveoli during dilatation. 
It may be due to the vibration of the lung 
substance from increased tension in in- 
spiration and the reverse in expira- 
tion. 
Character. 

Inspiratory sound. 

Quality, breezy, rustling, soft, vesicular. 
Pitch, low compared with that of laryn- 
geal breathing. 
Intensity, variable. 

Duration, coincident with the inspiratory 
act. 
Expiratory sound. 

Quality, like the inspiratory but less vesic- 
ular. 
Pitch, lower than that of the inspiratory 

sound. 
Intensity, variable ; the sound may not 

be appreciable but is generally so. 
Duration, much shorter than the expira- 
tory act. 
Rhythm : the ratio of the inspiratory to 
the expiratory sound is about three 



74 PHYSICAL DIAGNOSIS OF THE CHEST. 

to one, there being a slight interval 
between them. 
Variation in character largely depends upon 
the nearness of the point of auscultation 
to the large bronchi. 
Bronchial Breathing 1 . 
Locality and Cause. 

Normal, heard over the trachea. 
Abnormal (as a sign of disease), heard over 
consolidated lung, the main bronchi lead- 
ing to which are patulous, consolidated 
lung being a better medium of conduction 
of the sound from the larynx. It is'heard 
in pneumonia and phthisis. 
Character, it is substantially like that of 
tracheal breathing, though slightly less in- 
tense. 
Laryngeal and Tracheal Breathing differ from 
each other but little. 
Locality, heard over the larynx and trachea. 
Character. 

Inspiratory sound. 

Quality, tubular, blowing, but changing 
in harshness with the force of the act. 
Pitch, higher than that of the inspiratory 
sound of normal vesicular breathing, 
and varying in pitch with the force of 
the act. 
Intensity, great but variable. 
Duration, a little shorter than the inspira- 
tory act. 
Expiratory sound. 

Quality, very similar to that of inspiration. 
Pitch, higher than that of inspiration. 
Intensity, greater than that of vesicular 
breathing. 



METHODS OF PHYSICAL DIAGNOSIS. 75 

Duration, longer than that of the expira- 
tory sound of vesicular breathing. 
Rhythm : the expiratory sound is as long 
as the inspiratory, and a short interval 
exists between them. 
Cavernous Breathing-. 

Locality (it is an abnormal sound) heard 

over some pulmonary cavities. 
Cause, empty pulmonary cavity with easily 
collapsing and expanding walls in expira- 
tion and inspiration. 
Character. 

Inspiratory sound. 

Quality, soft, blowing, or puffing, but 

neither vesicular nor tubular. 
Pitch, low. 

Intensity, variable, but usually slight. 
Duration, variable. 
Expiratory sound. 

Quality, like that of the inspiratory sound. 
Pitch, lower than that of the inspiratory 

sound. 
Intensity, variable, but usually slight. 
Rhythm : the expiratory sound is about 
the same length as the inspiratory. 
Broncho-cavernous Breathing-. 

Locality and Cause, cavity surrounded bv 
solidified lung, as is found sometimes in the 
late stage of tuberculosis, abscess, or gan- 
grene. 
Character, both cavernous and bronchial 

elements are heard together. 
Varieties, metamorphosing breathing ; here 
the inspiratory sound is bronchial at first, 
but suddenly becomes cavernous. 
Vesiculocavernous. 



76 PHYSICAL DIAGNOSIS OF THE CHEST. 

Locality and Cause, cavity covered by more 

or less healthy lung. 
Character, as indicated by its name. 
Amphoric Breathing 1 . 

Locality, over a large cavity with relatively 
rigid walls and with a large opening, as may 
be obtained in tuberculosis and occasionally 
in pneumothorax. 
Cause, the peculiar vibration of air in its 
passage in and out of, or across the mouth 
of a flask-like cavity. 
Character. 

Inspiratory sound most distinct. 

Quality, musical, hollow, metallic, harder 

than that of cavernous breathing. 
Pitch of expiratory sound lower than that 

of bronchial breathing. 
Intensity, usually greater than that of 

cavernous breathing. 
Rhythm : amphoric breathing is usually 
heard best in inspiration. 
Intensity of Respiratory Sounds. 

Exaggerated, Supplementary, or Puerile 
Breathing*. 
Locality. 

Normal in childhood, the chest-walls being 

thin and elastic. 

Abnormal, over one lung when the other is 

crippled by consolidation, obstruction, 

etc. ; over healthy parts of a crippled lung. 

Cause, the lung is performing more than its 

usual function. 
Character, like that of normal vesicular 
breathing, except of greater intensity ; both 
inspiratory and expiratory sounds are louder 
and longer than usual. 



METHODS OF PHYSICAL DIAGNOSIS. 77 

Feeble Respiration. 
Locality. 
Normal. 

Over thick chest-walls, as in muscular or 
fat persons ; over the female mammae 
and over the scapulae. 

At a distance from the large bronchi, over 
the lower part of the chest, especially 
in women. 

In superficial breathing. 

The vesicular murmur is normally less 
intense on the right than on the left 
side. 
Abnormal from 

Imperfect transmission, due to oedema or 
swelling of the chest- walls ; air, fluid, 
or inflammatory lymph in the pleural 
sac. 

Loss of elasticity of the lung, emphysema. 

Partial blocking of the air-cells with blood 
or serum, as in pulmonary oedema. 

Consolidation of lung with filling up of 
the bronchi. 

Obstruction of the larynx, trachea, or 
bronchi from a collection of pus, mucus, 
blood, or fibrin ; foreign body ; thick- 
ening of the mucous membrane ; pres- 
sure of tumors. 

Constriction of the tubes from muscular 
contraction, asthma, bronchiolitis. 

Deficient action of the respiratory muscles. 
Mechanical obstruction, as in tympany, 

ascites, abdominal tumors. 
Pain, as in pleurisy, peritonitis, pleuro- 
dynia, neuralgia. 
Paralysis of the diaphragm. 



78 PHYSICAL DIAGNOSIS OF THE CHEST. 

Suppressed Respiratory Sound ; entire absence 
of respiratory sounds. 
Locality and Cause, an exaggeration of the 
conditions which produce feeble respiration : 
pneumo-thorax, hydro-thorax, occlusion of 
the larger air-passages. 
Hhythm of Mespiratory Sounds. 

Interrupted, Jerking", Wavy or Cog-Wheel 
Respiration. 
Locality. 

Normal, in nervous persons, agitated by ex- 
amination ; here it is apt to be heard more 
or less over the whole chest, but it may 
be localized ; sometimes it is heard in 
healthy persons from no apparent cause. 
Abnormal, it may accompany : 

Pain, as in pleurisy, pleurodynia, inter- 
costal neuralgia ; it is generally heard 
over the whole chest. 
Phthisis, here it may be an early sign, 
localized over the affected apex. 
Cause of cog-wheel breathing : in some cases 
(pain and nervousness) it may be due to the 
irregular and undecided manner of respira- 
tion, in others (phthisis) it is probably caused 
by the break or delays in the passage of air 
through the affected bronchioles. 
Character : either the inspiratory or expira- 
tory sound, or both, may be broken into 
several parts, or may be characterized by 
successive variations in intensity ; usually 
it is most marked in inspiration. 
Interval between Inspiration and Expiration 
may be more or less prolonged. 
In emphysema, owing to a deferred expira- 
tory sound. 



METHODS OF PHYSICAL DIAGNOSIS. 79 

In consolidation of the lung owing to short- 
ening of the inspiratory sound. 
Shortened Inspiratory Sound. 

Locality (where and when heard) and Cause. 
In emphysema it is due to the beginning of 
the respiratory act before the beginning 
of the sound. 
In consolidation (bronchial breathing) it is 
due to the ending of the inspiratory sound 
before the ending of the inspiratory act. 
Character. 

When due to emphysema. 
Quality, vesicular. 
Pitch, comparatively low. 
When due to consolidation. 
Quality, tubular. 
Pitch, high. 
Prolonged Expiratory Sound. 
Locality. 

Normal, over the right apex; sometimes pro- 
longed expiratory sound over the left apex 
in slightly less degree ; over the larynx, 
trachea, and bronchi (vide the landmarks). 
Abnormal, over consolidated lung; over a 
cavity ; over emphysematous lung ; in 
asthma ; in case of certain valve-like ob- 
stacles in the air-passages. 
Cause : difficult and prolonged exit of air 
from the lungs — e. (/., in emphysema, ow r ing 
to loss of elasticity of the lung ; in asthma, 
owing to spasm of the bronchial muscles. 
Character. 

When due to solidification of the lung. 
Quality, tubular. 
Pitch, high. 
When due to a cavity. 



80 PHYSICAL DIAGNOSIS OF THE CHEST. 

Quality, blowing, cavernous or amphoric. 
Pitch, low. 
When due to emphysema. 
Quality, vesicular. 
Pitch, low. 
When due to asthma. 
Both quality and pitch are obscured by 
dry rales. 
VOCAL SOUNDS. 

Elements of Sound : these are like those consid- 
ered in respiration and percussion, though not 
all of them are so significant in the consideration 
of vocal sound. 
Varieties of Vocal Sound. 
Normal (Vesicular) Vocal Resonance. 
Locality, it is heard 

Over the lung at a distance from the trachea 

and bronchi while the person is speaking. 

In adult males it is generally heard over the 

entire lung. 
In women and children it is heard over the 
upper part of the chest, and but indis- 
tinctly over the lower part. 
Cause : it is due to the transmission of the 
voice through the parenchyma of the lung 
and the chest-wall. 
Character. 

Quality, diffused, muffled, buzzing, seeming 
to come from the deep parts, of the lung 
(articulation not transmitted). 
Pitch, varies with the pitch of the voice. 
Intensity, greater over the right apex than 
over the left, especially in the infra-clav- 
icular region. 
Variations from the normal are chiefly in 
intensity. 



METHODS OF PHYSICAL DIAGNOSIS. 81 

Diminished vocal resonance. 

Locality and cause : it is the result largely 
of those conditions which cause feeble 
respiratory sounds. 
Exaggerated vocal resonance. 

Locality : it is heard over moderately con- 
solidated lung ; pneumonia, phthisis, etc. 
Cause, consolidated lung is a better me- 
dium for transmitting sound from the 
larynx than is ordinary lung tissue. 
Character : it differs from normal vocal 
resonance simply in being more intense, 
seeming to come from a point not far 
distant from the surface. It is usually 
associated with broncho- vesicular respi- 
ration. 
Bronchophony or Bronchial Voice. 
Locality. 

Normal, heard over the main bronchi. 
Abnormal, heard. 

Over consolidated lung as in the second 
stage of pneumonia, phthisis ; above the 
level of the fluid in pleuritic effusion. 
Over a vomica with firm walls (some- 
times), surrounded by consolidation. 
Cause, consolidated lung a better medium of 

transmission. 
Character. It is more concentrated than nor- 
mal vocal resonance and exaggerated vocal 
resonance, seeming to come from a point 
near the ear, immediately under the steth- 
oscope (no distinct articulation). It is usually 
associated with bronchial breathing, though 
not necessarily. Its pitch varies, and its in- 
tensity also, though usually increased above 
that of normal resonance. 



82 PHYSICAL DIAGNOSIS OF THE CHEST. 

Varieties of Bronchophony. 
JEgophony (goat voice). 

Locality, over consolidated lung, covered 
by a thin layer of fluid in the pleural 
cavity, as in pleuro-pneumonia with 
slight pleuritic effusion. 
Character, it is like that of bronchophony, 
except that it is of less intensity and 
has a tremulous sound, seeming to come 
from a considerable depth. 
Pectoriloquy (speaking through the chest). 
Locality and cause. It is heard 

1. Over consolidated lung, phthisis, 

pneumonia. 

(a) Quality, clanging, metallic. 

(b) Pitch, high. 

2. Over a cavity with smooth walls and 

a large opening, abscess, bron- 
chiectasis, etc. 

(a) Quality, soft. 

(b) Pitch, low. 

Character, it is like that of bronchophony 
with the addition of distinct articula- 
tion in the transmitted voice. 
Amphoric Voice. 

Locality, over pneumo-thorax or pulmonary 

cavity with a free opening. 
Character. 

Quality, hollow, musical. 
Pitch and Intensity, variable. It is fre- 
quently associated with amphoric respira- 
tion and resonance. 
WHISPERING SOUNDS. 

Normal Whispering Resonance. 
Exaggerated Whispering Resonance* 
Whispering Bronchophony. 



METHODS OF PHYSICAL DIAGNOSIS 83 

Cavernous Whisper. 
Whispering Pectoriloquy. 
Amphoric Wh isper. 

These whispering sounds correspond largely in 
locality, cause and character to the vocal sounds, 
the sound of phonation being substituted by that 
of aspiration. 
TUSSIVE OR COUGH SOUNDS. Cough though a 
symptom is a sign of importance. 
Definition. A deep inspiration is followed by 
closure of the glottis, contraction of the mus- 
cles of expiration, rise of tension within the 
pulmonary air-passages, and sudden opening of 
the glottis with violent explosive escape of the 
compressed air and fibration of the vocal cords. 
Relation to Auscultation. Much the same laws 
govern the sounds produced by coughing as 
apply to vocal sounds in auscultation of the 
chest. 

Cough may Remove Temporary Obstacles 
from the air-passages, thereby changing or 
destroying sounds. 
It Necessitates Subsequent Deep Inspiration 
with consequent distention of the air-vesicles. 
Varieties of Coagh. It is dry or moist according 
to the amount and character of the accompany- 
ing secretion. 

Laryngeal Cough, hacking, often spasmodic, 
and due to laryngitis, local irritation, or to 
reflex nervous trouble. 
Bronchial Cough, dry or tight, quick, harsh, 
and brassy. Loose, more or less rattling, 
owing to secretion within the tubes. It is 
frequently accompanied by pain along the 
attachments of the diaphragm, and more or 
less soreness under the sternum. Bronchitis. 



84 PHYSICAL DIAGNOSIS OF THE CHEST. 

Cavernous Cough has a hollow quality, and is 
usually intense and accompanied by gurgling 
sounds. 
Amphoric Cough is ringing, with the peculiar 
resonance heard in blowing across the neck of 
a bottle. 

The terms cavernous and amphoric cough 
refer to sounds heard upon auscultation 
in certain cases where cavities open into 
large bronchi. 
Causes of Cough. It may be 
Voluntary, or may be 
Involuntary, due to stimulation of the 

Nerve centre in the floor of the fourth ven- 
tricle. 
Reflex. 

Nerve-trunks. 

Vagus or superior laryngeal nerves. 
Peripheral. 

Direct stimulation of the mucous mem- 
brane of the air-passages by irritat- 
ing particles, cold air, etc. Espe- 
cially the surface of the 
Soft palate and pharynx. The 
Larynx is the most sensitive part of the 

air-passages. 
Trachea and bronchi : the most sensi- 
tive part is at the bifurcation of the 
trachea. 
Indirect stimulation. 

Irritation of the pleura (the costal layer) 

as in pleurisy. 
Irritation of the auditory meatus. 
Decayed teeth. 
Irritation of the post nares. 
Irritation of the skin by cold draughts. 



METHODS OF PHYSICAL DIAGNOSIS 85 

Derangement of the stomach possibly a 
cause of cough. 
ADVENTITIOUS SOUNDS. 
Utiles. 

Moist Rales. 

Large, coarse, or mucous rales. 

Locality, where produced : large and middle- 
sized tubes ; " death rattle " heard in the 
trachea. 
Cause, air bubbling through fluid, whether 

mucus, blood, or pus. 
Character. 

Quality, bubbling, moist. 
Pitch, usually low but variable. 
Intensity, variable. 

Duration, they may be removed by cough- 
ing or deep inspiration. 
Rhythm, they may accompany inspiration, 
expiration, or both. 
Condition, acute and chronic bronchitis, pro- 
fuse pulmonary hemorrhage, etc. 
Small, fine, mucous, or subcrepitant rAles. 
Locality, small tubes. 
Cause, air bubbling through fluid. 
Character. 

Quality, moist, fine, bubbling, or crack- 
ling or sticky (mixed in size). 
Pitch, varying with size of tube and con- 
dition of surrounding lung. 
Intensity, variable. 
Duration, they may be removed by deep 

inspiration or cough. 
Rhythm, they may accompany either or 
both acts of respiration. 
Condition, capillary bronchitis, third stage 
of tuberculosis, lobular pneumonia, pul- 



86 PHYSICAL DIAGNOSIS OF THE CHEST. 

monary congestion and oedema, severe 
hemorrhage, chronic bronchitis, etc. 
Dry Rales. 

Sonorous Kales. 
Locality, large tubes. 

Cause, narrowing of the lumen of the 
bronchi, from viscid mucus adhering to 
their wall ; swelling of the mucous mem- 
brane ; spasm of the annular bronchial 
muscles ; fibroid contractions ; pressure 
upon the bronchi by an aneurysm or other 
tumors or swellings. 
Character. 
Quality, snoring. 
Pitch, low. 

Intensity, variable, usually very loud. 
Duration, they are usually not removable 
by cough or deep inspiration, except 
when due to viscid mucus. 
Rhythm, they may accompany either or 
both acts of respiration. 
Conditions, asthma, bronchitis, and other 
more rare conditions causing narrowing 
of the tubes* 
Sibilant RAles. 
Locality, small tubes. 
Cause, same as that of sonorous rales. 
Character. 

Quality, whistling, hissing, creaking. 
Pitch, high. 

Intensity, less than sonorous, but variable. 
Duration, they may be removed by cough 

or deep inspiration. 
Rhythm, they may accompany either or 
both acts of respiration. 
Conditions, asthma and bronchitis. 



METHODS OF PHYSICAL DTAGXOSIS. S7 

Crepitant Ralks. 

Locality, they are produced in the ultimate 

air-vesicles. 
Cause (probably), sudden separation of the 
walls of collapsed air-vesicles, adhering 
more or less, from the presence of fibrinous 
exudate upon their surfaces. 
Character. 

Quality, like the crackling of salt thrown 
upon the fire, dry, very fine, numerous, 
and uniform in size, as compared with 
subcrepitant rales, which are coarser, 
bubbling, moist, fewer in number, and 
of different sizes. 
Pitch, high. 
Intensity, variable. 

Duration, they are not disturbed by cough. 
Rhythm, they are never heard in expira- 
tion, always in inspiration, usually at 
its end. 
Condition, typically in the first stage of 
lobar pneumonia, sometimes in incipient 
tuberculosis at the apex of a lung ; rarely 
in pulmonary hemorrhage and oedema. 
They may frequently be found at the 
lower part of the posterior aspect of the 
chest for a few deep inspirations in feeble 
persons who have been in the recumbent 
posture for some time. 
Indeterminate Rales. 
Crumpling sounds. 
Locality. 

Normal, sometimes heard at the end of 
a forced inspiration, usually bilateral. 
Abnormal, they are sometimes heard in 
emphysema. 



88 PHYSICAL DIAGNOSIS OF THE CHEST. 

Cause, none known definitely. 
Character, something like the sound of 
parchment when wrinkled, and occur- 
ring at the end of forced inspiration. 
Condition, emphysema. 
Friction Sounds. 

Locality, over inflamed pleura or pericardium, 

rarely over the peritoneum. 
Cause, rubbing together of two serous surfaces, 
roughened by exudate, or dry from diminished 
secretion. 
Character. 

Quality, rasping, grating, grazing, creaking, 
simulated by rubbing the hand upon the 
chest during auscultation. They are few in 
number compared with rales, and are irreg- 
ular in occurrence. 
Duration, they are not removable by cough 

or deep inspiration. m 

Rhythm, usually they are most prominent at 
the end of inspiration or beginning of ex- 
piration. 
Condition, pleurisy and pericarditis in the first 
stage ; rarely in peritonitis over the spleen or 
liver. 
Unclassified Adventitious Sounds. 
Metallic Tinkling*. 
Locality. 

Normally, it may be heard at times over the 

stomach. 
Abnormally, over the pleural cavity contain- 
ing air and fluid, especially when com- 
municating with a bronchus above the 
level of the fluid. 
Cause : the dropping of fluid in a cavity con- 
taining fluid and air. 



METHODS OF PHYSICAL DIAGNOSIS. 89 

Character. 

Quality, silvery, tinkling, or splashing. 
Pitch, high. 

Intensify, slight, but variable. 
Rhythm, either in inspiration or expiration, 
or during cough, or occasionally inde- 
pendent of them. 
Condition, pneumo-hydrothorax, pulmonary 
abscess, etc. 
Splashing- or Succussion Sound. 

Locality, same as that of metallic tinkling. 
Cause, splashing of fluid within an air-con- 
taining cavity, heard when the body is 
shaken, with the ear of the examiner against 
the surface, over the part. 
Character, splashing. 

Condition, pneumo-hydrothorax or pneumo- 
pyothorax. 
Bell Sound. 

Locality, it is heard over a large air-contain- 
ing cavity. 
Cause : with the ear against the cavity, per- 
cussion is made upon the chest at the oppo- 
site side of the cavity, two coins being used 
as plexor and pleximeter ; the sound heard 
is due to the vibration of the air within the 
cavity. 
Character, ringing, hollow, metallic. 
Condition, pneumothorax. 
S O LXJDS PR OI) LCED B Y THE CIH C VLA TOR Y 
MECHAXISM. 
CARDIAC SOUNDS. 

Normal Cardiac Sounds. 
First Sound of the Heart. 

Cause of the first sound : it is chiefly due to 
the closure of the auriculo-ventricular valves 



90 PHYSICAL DIAGNOSIS OF THE CHESt. 

(mitral and tricuspid). To a slight extent 
this sound may also be due to contraction 
of the walls of the ventricle in systole, the 
impulse of the apex against the chest-wall, 
and the rush of blood through the ven- 
tricles. 
Elements of the first sound. 

Mitral element, heard best at the apex, and 
behind at the angle of the scapula. It is 
slightly louder than the tricuspid. 
Tricuspid, element, heard best at the lower 
end, a little to the left, of the sternum. 
Character of the first sound. 

Quality, " lubb," dull, soft, booming, 
v Pitch, lcwer than that of the second sound. 

Intensity, greatest at the apex beat, varying 
with the strength of the heart, the condi- 
tion of the valves and cavities, and the 
amount of tissue interposed between the 
heart and the listening ear. 
Duration, long as compared with the second 

sound. 
Rhythm, systolic, synchronous with the sys- 
tole of the ventricles, the apex beat, and 
carotid pulse ; preceded immediately by 
the long pause, succeeded immediately by 
the short pause. 
Second Sound of the Heart. 

Cause of the second sound : it is chiefly due 
to the closure of the semilunar valves, aug- 
mented by the vibration of the neighboring 
parts. 
Elements of the second sound. 

Aortic element, heard best in the second 
intercostal space, close to the right of the 
sternum. 



METHODS OF PHYSICAL DIAGNOSIS. 91 

Pulmonic element, heard best in the second 
intercostal space to the left of the ster- 
num ; not so loud as the aortic. 
Character of the second sound. 

Quality, "dupp," sharp. 

Pitch, higher than that of the first sound. 

Paternity, greatest at the base of the heart ; 
variable like the first sound. 

Duration, shorter than the first sound. 

Rhythm, it is preceded immediately by the 
short pause, and succeeded immediately 
by the long pause. The relation of the 
first and second sounds with the inter- 
vening pauses may be represented thus : 

"lubb," — "dubb," . 

Modifications of the Normal Heart Sounds. 
Modification of the First Sound, in 
Intensity and duration. 

Diminished intensity of the first sound, from 
Weakness of the heart as a result of — 

1. General diseases, fevers, chronic 
wasting disorders, aneurysm, etc. 

2. Local diseases of the heart : fatty 
degeneration or infiltration ; atrophy, 
amyloid, or fibroid degeneration ; 
valvular disease ; pericardiac effu- 
sion, etc. 

Interposition of tissues, as in emphysema, 
pleuritic effusion, thick chest- walls from 
fat or muscle. 
Increased intensity and duration of the first 
sound ; it may be 

Longer in duration, loud and booming, 
as in hypertrophy of the left ventricle 
from cirrhotic kidney ; aortic stenosis 
and sometimes in aortic aneurysm, or 



92 PHYSICAL DIAGNOSIS OF THE CHEST. 

Shorter in duration and sharper, as in 
case of thin chest-walls, emotional ex- 
citement, physical exertion, onset of 
febrile disease. 
Quality : the first sound may be impure ; it 
may be sharper or duller than usual, more 
flapping or clacking. 
Rhythm. 

Reduplication. 

Cause : non-synchronous action of the 
mitral and tricuspid valves, or possibly 
non-synchronous action of the cusps of 
either valve. 
Character, as related to the second sound ; 
it may be represented thus : " lubb," 

"lubb," — "dupp," . 

Frequency : it is not uncommon, but the 
second or diastolic sound is more fre- 
quently reduplicated than the first or 
systolic sound of the heart. 
Significance : it is usually temporary, but 
may be permanent ; it is either physio- 
logical or pathological, and it is not 
peculiar to any particular lesion or con- 
dition. 
Irregularity may involve time or intensity, 

or both. 
Intermittency or dropping of the first sound. 
Modification of the Second Sound. 
Intensity. 

Diminished intensity of the second sound 

from 

Diminished power of the right or left 

ventricle, by which less blood is thrown 

into the aorta and pulmonary artery, 

producing less tension in them, and 



METHODS OF PHYSICAL DIAGNOSIS. 93 

hence, less forcible recoil of their elas- 
tic walls, and less sudden and forcible 
closure of the semilunar valves. 

1. General debilitating diseases, or 

2. Local diseases impairing the 
strength of the heart or elasticity 
of the main arteries. 

Stenosis of the mitral or tricuspid orifices 
or of the orifices of the aortic or pul- 
monary artery, reducing the tension in 
those vessels. 
Lesion of the pulmonary or aortic valves 
impairing their closure. 
Increased intensity or accentuation of the 
second sound. 
Pulmonic second sound may be accen- 
tuated as a result of increased tension 
in the pulmonary artery from hyper- 
trophy of the right ventricle ; ob- 
structed pulmonary circulation depend- 
ent upon pulmonary disease or valvular 
disorder of the left heart. 
Aortic second sound may be accentuated 
as a result of increased tension in the 
aorta from hypertrophy of the left ven- 
tricle or obstruction in the aortic or 
general circulation : chronic renal dis- 
ease and some cases of aortic an- 
eurysm. 
Quality : the second sound of the heart may 
be sharper or duller, or flopping or more 
booming in character. 
Rhythm. 

Reduplication of the second sound. 

Cause : non-synchronous action of the 
aortic and pulmonic valves, or possibly 



94 PHYSICAL DIAGNOSIS OF THE CHEST. 

non-synchronous action of the cusps of 
either of these valves. 
Character, as related to the first sound it 
may be represented thus: "lubb," 
— - " dupp," " dupp," — . 
Frequency and significance (vide redupli- 
cation of the first sound). 
Irregularity and 

Intermittency of the second sound (vide first 
sound of the heart). 
Abnormal Cardiac Sounds or Murmurs. 
Exocardial Murmurs. 

Pericardiac friction sounds. 

Locality, over the prsecordia, usually best 
heard over the base of the heart, or over 
the junction of the left fourth costal car- 
tilage with the sternum. 
Cause, inflammation of the pericardium 
causing roughness and dryness of the 
membrane in the first and at the end 
of the third stage. 
Character. 
Quality, rubbing, grating, rasping, creak- 
ing. 
Intensity, variable, increased by forced 
expiration, by pressure of the steth- 
oscope, and by forward inclination of 
the patient. They seem to be more 
superficial than endocardial murmurs. 
Rhythm, independent of respiration and 
synchronous with systole or diastole, 
or both. 
Pericardiac splashing and churning 
sounds have been heard occasionally in 
cases of sero- or pyo-pneumo-pericardium. 
Pleuro-pericardiac friction sounds similar 



METHODS OF PHYSICAL DIAGNOSIS. 



95 



111 character to pleuritic friction sounds, but 
produced by the motion of the heart in sys- 
tole, causing to-and-fro rubbing of the in- 
flamed pleura. The pleura alone, or both 
the pleura and pericardium, may be in- 
volved in the inflammation. 



svc 




Fig. 8.— Normal blood-currents in the heart and relative position of the ventri- 
cles, auricles, and great vessels. IVC, inferior vena cava; SVC, superior vena 
cava ; PA, right auricle : TV, tricuspid valves ; R V, right ventricle ; P, pulmonary 
valves ; PA, pulmonary artery ; Pv, pulmonary veins ; LA, left auricle ; MV, mitral 
valves ; LV, left ventricle ; A, aortic valves ; Aa, arch of aorta. (From Page.) 



Pneumo-pericardiac or cardio-pulmonary 
sounds are soft blowing murmurs of rare 
occurrence, produced by the motion of the 
heart in forcing air from an adjacent pul- 
monary cavity, the air supposedly being ex- 
pelled from the cavity in systole and return- 
ing during diastole. 
Endocardial Murmurs include organic and in- 
organic. 



96 PHYSICAL DIAGNOSIS OF THE CHEST. 

Organic endocardial murmurs include val- 
vular and non-valvular. 
Valvular, organic, endocardial murmurs in- 
clude systolic and diastolic. 
Systolic, organic, valvular murmurs in- 
clude those of the right and those 
of the left heart. 

Time ( Direct C Aortic. 

of < (Obstructive). 1 Pulmonic, 
murmurs. ( j A- rec t i Mitral. rDiastole of ventricles. 

L. /r, •. .% l Tricuspid. ^/v 




rgitant).' Tricus P id - 



.:.' ,:',; : ■■■::>■■. <■,■ .. ,i ■■■- , ; 



Short 
interval. 



1 






Long interval. 



. / ( Aortic. Ti 




Systole of auricles. 

-Y, ,p. / ( Aortic. Time f Mitral. 

S y stole - T,me Indirect ., of I Direct 

1 (Regurgitant). murmurs. \ (Obstructive). 

murmurs - [Pulmonic. ; (Presystolic.) [Tricuspid- 
Indirect Direct 

(Regurgitant). (Obstructive). 

Fig. 9.— Diagram showing the time of valvular murmurs in the cardiac cycle. 
The cardiac cycle is divided into tenths. The first sound occupies four-tenths ; the 
short interval, or silence between first and second sounds, occupies one-tenth; the 
second sound occupies two-tenths ; the long interval following second sound occu- 
pies three-tenths ; the systole of the ventricles occupies the time of the first sound 
and the short interval. 

Relation of murmurs to the heart-sound : murmurs may precede, occur with, or 
take the place of the heart-sounds. Their time is indicated in the diagram by 
arrows. 

1. Of the left heart. 

(a) Mitral systolic, indirect, or re- 
gurgitant murmurs. 
Cause : insufficiency of the mitral 
valve from 

Tearing or perforation of a cusp. 

Inflammatory retraction of the 
cusps. 

Rigidity of the cusps. 

Vegetations, preventing closure. 

Rupture or shortening of the 
chordae tendinese. 

Dilatation of the left ventricle 
without compensatory length- 
ening of the chordae. 



METHODS OF PHYSICAL DIAGNOSIS. 97 

Spasm of the columnse carnese. 
Usual accompanying symptoms 
and signs : 

Pulse, compressible and more or 
less irregular. 

Indications of pulmonary, he- 
patic, and renal congestion 
with oedema of the feet and 
ankles are common in cases 
of non-compensation. 

Enlargement of the left heart, 
with especial increase in trans- 
verse diameter. 

Pulmonic second sound accen- 
tuated. 
Character of the murmur of mitral 
regurgitation : 

Quality, apt to be blowing and 
soft.' 

Rhythm, systolic, accompany- 
ing, or replacing, the first 
sound of the heart at the 
apex. 

Intensity, varies in different 
cases, but the loudness of a 
murmur is not proportionate 
to, and does not indicate the 
severity of the lesions causing 
it. This is equally true of 
all organic murmurs. 
Area of maximum intensity is at 

the apex. 
Propagation of the murmur is fre- 
quently to the left of the apex ; 

it is often heard at the lower 

angle of the scapula, but is not 



98 PHYSICAL DIAGNOSIS OF THE CHEST. 

usually heard at the base of the 
heart, and is never transmitted 
into the carotids. The trans- 
mission of murmurs to the left 
of the apex depends upon the 
following factors : 
Time : whether or not it occurs 
when the apex of the heart 
strikes the chest- wall (systole). 
Enlargement of the heart. 
Position of the heart relative to 
the transverse diameter of the 
chest-cavity. 
Condition of the left lung. 
Thickness of the chest-wall. 
Intensity of the murmur. 
Frequency of the murmur of mitral 
regurgitation, it is the most fre- 
quent of all valvular murmurs. 
(6) Aortic systolic, direct murmur. 
Cause : 

Obstruction at the orifice, 
guarded by the aortic semi- 
lunar valve due to thickening 
and rigidity of the cusps from 
fibroid, calcareous, or athero- 
matous change ; vegetations ; 
adhesion of the cusps ; indu- 
ration and contraction of the 
fibrous ring or margin of the 
aortic opening ; congenital 
malformation (rare). 
Simple roughening of the cusps. 
Marked dilatation of the aorta 
immediately beyond the val- 
vular opening, the latter re- 



METHODS OF PHYSICAL DIAGNOSIS. 99 

maining relatively normal in 
size. 
Usual accompanying symptoms 
and signs in cases of marked 
obstruction : 

Pulse : hard, wiry, small, but 
regular unless the heart be 
greatly embarrassed. 

Thrill or fremitus often felt over 
the base of the heart, espe- 
cially over the aortic area. 

Evidence of cerebral anaemia 
not uncommon ; 

Enlargement of the left heart ; 

Pulmonic second sound, feeble ; 
and 

Aortic second sound, feeble or 
inaudible. 
Character of the aortic direct mur- 
mur : 

Quality, usually harsh when due 
to stenosis or marked obstruc- 
tion, otherwise it is apt to be 
soft. 

Rhythm, systolic, with the first 
sound. 
Area of maximum intensity : the 

right, second intercostal space 

close to the sternum, sometimes 

over the left interspace or over 

the upper part of the sternum 

at the same level. 
Propagation, into the arteries of' 

the neck and down the sternum, 

and toward the apex, but with 

diminished intensity. It is also 



100 PHYSICAL DIAGNOSIS OF THE CHEST. 

frequently heard when loud, be- 
hind to the left of the fourth 
dorsal vertebra, but is not usually 
transmitted to the left of the 
apex. 
2. Of the right heart (systolic, organic, 
valvular murmurs), 
(a) Tricuspid systolic, indirect or re- 
gurgitant murmur. 
Causes may be similar to those of 
mitral regurgitant murmur, but 
usually it results from relative 
incompetency of the valve in 
dilatation of the right ventricle, 
secondary to diseases of the 
lungs or serious lesions of the 
left heart. 
Usual accompanying symptoms 
and signs : Commonly pulmon- 
ary diseases or lesions of the left 
precede those of the right heart ; 
the associated manifestations are 
often those of 

Congestion of the brain and 
abdominal organs; pulsa- 
tion of the 
Jugular and sometimes of the 
Hepatic veins. 

Enlargement of the right 
heart and usually of the 
left. 
Pulmonic second sound,feeble. 
Character of the murmur of tri- 
cuspid regurgitation : 
Quality, blowing. 
Rhythm, systolic, with or re- 



METHODS OF PHYSICAL DIAGNOSIS. 101 

placing the first sound of 
the heart. 
Area of maximum intensity, the 
tricuspid area at the end of and 
along the left side of the sternum: 
Propagation very limited ; if any- 
where, it is transmitted to the 
right, sometimes even to the 
axilla. It is not heard at the 
apex or behind or over the ca- 
rotids, and is seldom audible 
above the third rib. 
Frequency : it is comparatively 
rare, and very uncommon, from 
primary lesion of the tricuspid 
valve. 
(b) Pulmonic, systolic, direct mur- 
mur. 
Cause : usually obstruction from 
conditions somewhat similar to 
those affecting the aortic orifice ; 
rarely are lesions of this valve 
the result of rheumatism. They 
are generally congenital. 
Usual accompanying symptoms 
and signs : 
Enlargement of the right heart ; 
Evidence of venous engorge- 
ment ; 
Bruit de diable occasionally 

heard over the jugulars. 
Pulmonic second sound weak. 
Character of the murmur of pul- 
monic obstruction : 
Quality, variable, apt to be 
harsh. 



102 



PHYSICAL DIAGNOSIS OF THE CHEST. 



Rhythm, systolic, accompanying 
the first sound. 
Area of maximum intensity : in 
the left second intercostal space 
close to the sternum. 
Propagation occasionally toward 
the left shoulder, never toward 
the apex nor along the aorta. 
It is not heard over the lower 
part of the sternum, nor be- 
hind. 
Frequency : very rare. 
Diastolic, organic, valvular murmurs. 
1. Of the left heart, 

(a) Mitral diastolic (presystolic), di- 
rect murmur. 
Cause : obstruction of the mitral 
opening. This murmur may 
possibly occur, according to 
Flint, without mitral lesion, 
where there is aortic regurgita- 
tion with marked dilatation of 
the left ventricle. 
Usual accompanying symptoms 
and signs : 
Pulse, in marked cases, small. 
Purring thrill or fremitus, pre- 
systolic and most distinct at 
the apex, not uncommon. 
Evidence of pulmonary engorge- 
ment. 
Enlargement of the left auricle. 
Pulmonic second sound accen- 
tuated. 
Character of the murmur of mitral 
stenosis : 



METHODS OF PHYSICAL DIAGNOSIS. 103 

Quality, harsh, churning, grind- 
ing, blubbering. 
Duration, it is apt to be longer 

than other murmurs. 
Rhythm, diastolic (presystolic), 
probably occurring in auricu- 
lar systole. 
Area of maximum intensity : at 
the apex beat or half an inch 
above it. Usually louder when 
the patient is erect. 
Propagation limited : not trans- 
mitted to the left of the apex, 
nor into the arteries of the 
neck, nor is it heard behind. 
Frequency : common. 
(b) Aortic, diastolic, indirect, regurg- 
itant murmur. 
Cause : insufficiency of the valve 
from much the same causes as 
those producing mitral insuffi- 
ciency, except those referring to 
the chordae tenclinese. 
Usual accompanying symptoms 
and signs : 
Pulse full, strong, and collapsing 
in diastole ; forcible beating 
of the 
Carotids. 
Capillary pulsation in -marked 

cases. 
Enlargement of the left heart, 
with perhaps secondary en- 
largement of the right. 
Character of the murmur of aortic 
regurgitation : 



104 PHYSICAL DIAGNOSIS OF THE CHEST. 

Quality, soft, blowing, rushing, 

and occasionally musical. 
Rhythm, diastolic, accompany- 
ing, or replacing, or imme- 
diately following the second 
sound of the heart. 

Area of maximum intensity : in 
the right second interspace, or 
over the sternum at the level of 
the second costal cartilage, fre- 
quently in the left, second in- 
terspace, and sometimes at the 
xiphoid cartilage. 

Propagation : down the sternum 
to the epigastrium ; to the apex, 
where it is sometimes very loud 
and conveyed to the left ; to the 
arch of the aorta and into the 
carotids ; and behind, along the 
right side of the spinal column. 
It may be heard occasionally 
even in the radial and femoral 
arteries. The area of diffusion 
is greater than that of any other 
murmur. 

Frequency : it stands third in order 
of frequency. 
- 2. Of the right heart. 

(a) Tricuspid, diastolic (presystolic), 
direct murmur. 

Cause : obstruction at the tricuspid 
opening (vide aortic and mitral 
stenosis). 

Usual accompanying symptoms 
and signs : those of systemic 
venous engorgement. Some- 






METHODS OF PHYSICAL DIAGNOSIS. 105 

times there is a fremitus to be 
felt over the right heart. 

Character of the murmur of tri- 
cuspid obstruction : 
Quality, harsh. 
Rhythm, presystolic. 

Area of maximum intensity : over 
the lower two-thirds of the 
sternum. 

Propagation : may be toward the 
base faintly, but never toward 
the apex ; it is not heard above 
the base. 

Frequency : extremely rare. 
(6) Pulmonic, diastolic, indirect, re- 
gurgitant murmur. 

Cause : insufficiency of the pul- 
monic valve, usually following 
pulmonary diseases or serious 
lesions of the left heart. 

Usual accompanying symptoms 
and signs are those of the ante- 
cedent lesion ; evidence of venous 
engorgement ; enlargement of 
the right heart. 

Character of the murmur of pul- 
monic regurgitation : 
Quality, soft, blowing. 
Rhythm, diastolic, accompany- 
ing or replacing the second 
sound. 

Area of maximum intensity : over 
the left, second intercostal space. 

Propagation : downward toward 
the xiphoid cartilage. 

Frequency : rare. 



106 PHYSICAL DIAGNOSIS OF THE CHEST. 

Non-valvular, organic murmur. 

Intra- ventricular or intra-auricular mur- 
murs. 
Cause : roughening of the endocardial 
lining in acute endocarditis ; rarely 
it may be due to a tendinous cord 
stretched across the ventricle (con- 
genital) ; or cardiac aneurysm ; or an 
abnormal congenital opening between 
the two cavities, patulous foramen 
ovale. 

Usual accompanying symptoms and 
signs : none constant, though they 
may be those of acute endocarditis. 
Character of the organic, intra-ven- 
tricular murmur : 
Quality, variable, usually soft. 
Rhythm, systolic. 
Area of maximum intensity at or 

near the apex. 
Propagation : limited. 
Frequency : quite common in acute 
endocarditis. 
Inorganic, or functional, endocardial 

MURMURS. 

Inorganic valvular murmurs. 

Systolic, inorganic, valvular murmurs. 
1. Of the left heart, 

(a) Mitral, systolic, inorganic, re- 
gurgitant murmur. 
May occur purely from functional 
incompetence without actual 
lesion of the valve. Its charac- 
ter does not differ from the or- 
ganic murmur. Such a murmur 
may appear and disappear with- 



METHODS OF PHYSICAL DIAGNOSIS. 107 

out previous, accompanying, or 
subsequent evidence of endo- 
carditis. 
Frequency : it is comparatively 
rare. 
(b) Aortic, systolic, inorganic mur- 
murs. 
Cause : anaemia. 

Accompanying symptoms and 
signs, those of 
Anaemia : pallor, lassitude, weak 

pulse, 
Venous hum over the jugulars, 

and frequently an 
Arterial, systolic murmur, pro- 
duced in the carotids which 
is usually of different quality 
and pitch from the cardiac 
murmur. 
No cardiac enlargement is present 
or other sign of valvular lesion. 
Character : 
Quality, soft. 
Rhythm, systolic. 
Area of maximum intensity : over 
the base of the heart, above the 
third rib, frequently in the aortic 
area. 
Propagation occurs into the arch 
of the aorta and the carotids ; 
frequently a louder murmur pro- 
duced in, and heard over the 
carotids, may accompany it. 
Frequency : the inorganic, aortic, 
systolic murmur is more com- 
mon than the organic. 



108 PHYSICAL DIAGNOSIS OF THE CHEST 

2. Of the right heart. 

(a) Tricuspid, inorganic, regurgitant 
murmur. 
Cause : functional incompetence 
of the tricuspid valve, similar 
to that of the mitral valve. 
(6) Pulmonic, systolic, inorganic mur- 
mur. 
Cause : anaemia. 

Character: similar to that of the 
aortic, systolic, inorganic mur- 
mur. 
Area of maximum intensity is over 

the pulmonary area. 
Propagation is limited : it is not 
transmitted above the base of 
the heart, but may be accom- 
panied by an anaemic murmur 
produced in the carotids, which 
is frequently of different quality 
and pitch. 
Diastolic, inorganic murmur of both left 
and right heart are very rare and prac- 
tically unimportant. 
Inorganic, non-valvular murmurs are in- 
definite and unimportant. 
VASCULAR SOUNDS, sounds heard over the vessels. 
Arterial Sounds. 

Normal Arterial Sounds. 

Diastolic second sound of the heart 
may be transmitted into the aorta and 
carotids. (It may be impure or entirely 
wanting.) 
Over the aorta and commonly over the 
carotid and subclavian arteries is to be 
heard a systolic, indistinct, rushing sound 



METHODS OF PHYSICAL DIAGNOSIS. 109 

produced by the blood pulsating through 
the arteries. 

Over the Subclavian arteries at the end 
of inspiration a systolic, blowing murmur 
may be frequently heard in health. 

Over the abdominal aorta and crural 
arteries is sometimes to be heard a pulsating 
sound, corresponding in rhythm to the pulse 
in those arteries. 

Over the small vessels nothing is to be 
heard. 

Pressure of the stethoscope over any of 
the large arteries may produce a murmur 
occurring with the local pulsation. 

Over the anterior foxtaxelle and some- 
times over the carotids of children, between 
the ages of three months and six years, 
a blowing, systolic murmur, of variable 
intensity, is frequently heard, " cerebral 
blowing." 

Over the uterus in the latter months of 
pregnancy, uterine souffle, from entrance of 
blood into the dilated arteries of the uterus. 
Abnormal Arterial Sounds. 

Over the aorta, carotid, and subclavian 
arteries may be heard systolic and diastolic 
murmurs produced at the aortic orifice of 
the heart ; in aneurysm of these vessels a 
systolic whizzing or blowing murmur may 
be heard over them, rarely a diastolic mur- 
mur in aortic aneurysm. 

Over the crural, brachial, radial, and 
ULNAR arteries, and even the peroneal 
and dorsal is pedis, a murmur may be heard 
with the pulse in the respective vessels in 
some cases of aortic insufficiency. 



110 PHYSICAL DIAGNOSIS OF THE CHEST. 

Over the crural arteries a systolic mur- 
mur may sometimes be heard in anaemia and 
chlorosis and in high fever (as well as occa- 
sionally in health). 

Over the crural arteries a double mur- 
mur, diastolic and systolic, may be heard in 
some cases of aortic insufficiency (Traube) ; 
exceptionally in mitral stenosis (Weil) ; in 
lead-poisoning (Matterstock) ; and in preg- 
nancy (Gerhardt). 

Over the crural arteries, also, in many 
cases of aortic insufficiency, a double mur- 
mur may be produced by the pressure of the 
stethoscope over the artery, " Duroziez's 
double murmur/ 5 This can only occur with 
a large, quick pulse. 

Over the subclavian artery a systolic 
murmur (sometimes normal, as when due to 
pressure of the stethoscope) may be pro- 
duced by pressure of tumors on the vessel ; 
traction by lung in fibroid disease of the 
apex. 
Venous Sounds, bruit de (Liable. 
Normal Venous Sounds. 

Over the jugular vein, most frequently 
the right, a venous hum, whistling, or rush- 
ing sound is exceptionally heard in health, 
either continuous or rhythmically syn- 
chronous with diastole or inspiration. It 
may be produced sometimes by pressure of 
the stethoscope, or by turning the person's 
head to the opposite side. 

Over the crural vein, occasionally in 
health, especially in thin persons, a sound 
may be heard, produced by sudden straining 
efforts or coughing (Friedreich). 



METHODS OF PHYSICAL DIAGNOSIS. Ill 

Abnormal Venous Sounds. 
Over the jugular vein. 

In tricuspid insufficiency a systolic murmur 

may sometimes be heard. 
In ancemia and chlorosis a venous hum more 
or less continuous is often present over 
this vessel, associated with a systolic, 
blowing murmur in the carotids. Venous 
murmurs arising in the cervical veins and 
in the intrathoracic venous trunks may 
exceptionally be conducted to the heart, 
simulating valvular murmurs. 
Cause uncertain. 
Character. 

Quality : whizzing, rushing, or hum- 
ming (like a singing top). 
Duration : intermittent or constant, but 

disappearing with the anaemia. 
Intensity : loudest over the right jug- 
ular, with the patient erect and the 
head turned to the left. The in- 
tensity is increased during ventricu- 
lar diastole, during inspiration, by 
moderate pressure of the stethoscope, 
and by quickening of the circulation. 
Over the crural veins, exceptionally, in 
tricuspid insufficiency may be heard a double 
sound, indicating first auricular then ven- 
tricular contraction (Friedreich) ; this is not 
easily distinguished from like murmurs pro- 
duced in the crural artery. 

SUCCUSSIOX. 

The succession or splashing sound is produced in a cavity 
which contains both fluid and gas, by shaking the patient. 
Normally, it may sometimes be heard over the stomach ; 



112 PHYSICAL DIAGNOSIS OF THE CHEST. 

pathologically, it is a sign of pneumo-hydrothorax. The 
character of the sound is like that produced when a small 
keg, partly filled with liquid, is shaken (vide p. 89). 



PHONOMETEY. 

The tuning-fork may aid in the detection of changes which 
have affected intrathoracic organs. If it be vibrated and 
placed over normal lung its sound is accentuated ; if over 
airless parts its sound is attenuated. 



PHYSICAL SIGNS IN THE DISEASES OF THE 

CHEST. 

Note. — A clear understanding of the morbid anatomy of 
a disease is essential to an appreciation of its physical signs. 
In the following synopsis, therefore, each disease, with a few 
exceptions, is introduced by a definition epitomizing its gross 
pathology. In the enumeration of the signs discovered by 
the several methods of objective examination the order will 
be followed, as far as practicable, as indicated in the preced- 
ing pages — viz. under inspection, color, nutrition, size, form, 
posture and movements, etc. 

DISEASES OF THE CHEST-WALL. 

PLEURODYNIA AND INTERCOSTAL NEURALGIA. 
Definition. 

PLEURODYNIA is a thoracic, rheumatic myalgia. 
INTERCOSTAL NEURALGIA is a functional or 
organic affection of the intercostal nerves, chiefly 
manifested by pain and localized points of tenderness, 
and usually affecting women. 



SIGNS IN THE DISEASES OF THE CHEST. 113 

Signs. 

IX8FECTIOX shows 

AN>EMIA commonly present. 

RESPIRATION in severe eases shallow and more or 

less rapid as evidence of pain. 
MOVEMENTS OF THE BODY restricted to avoid 
pain, especially in pleurodynia. 
FALFATIOX may reveal 
IN PLEURODYNIA— 

Tenderness on pressure, more or less DIFFUSE when 
superficial muscles are involved. 
IN INTERCOSTAL NEURALGIA— 

Tenderness in from one to three isolated points 
(Valleix's). 
Behind, near the dorsal vertebrae. 
Laterally, in one or more intercostal spaces along 

the axillary line. 
Anteriorly, in one or more intercostal spaces 
near the sternum or over the epigastrium. 
PEBCrsSIOX shows— 

ABSENCE OF DULNESS, unless there be compli- 
cating or causative disease of the lungs, pleurae, or 
circulatory organs. 
A LSC ZL TA TIOX yields— 

NORMAL VESICULAR RESPIRATION, except slightly 
diminished in intensity or interrupted owing to re- 
stricted movements. 
ABSENCE OF PLEURITIC SOUNDS and of crepitant 
rales. 

SWELLINGS AND TUMORS OF THE CHEST-WALL. 

Definition : these include inflammatory and granuloma- 
tous affections and tumors. 

Signs : the varying color, size, shape, location, tenderness, 
consistence, and movability of each affection, whether 
originating from or involving bone, cartilage, or soft 

8 



114 PHYSICAL DIAGNOSIS OF THE CHEST. 

parts, are properly considered in works on general sur- 
gery. Suffice it to say here, that the usual respiratory 
and vocal sounds are to a degree obscured over them 
and vocal fremitus correspondingly enfeebled. The ab- 
sence of positive signs of intrathoracic disease is sug- 
gestive of one or the other of these affections. 

EMPHYSEMA OF THE CHEST-WALL. 

Definition : a rare affection characterized by inflation of 
the subcutaneous areolar tissue with air or other gas. It 
is usually associated, when marked, with a like involve- 
ment of the cervical and abdominal region, and it may 
extend over the entire body. 
Signs. 

INSPECTION may reveal— 
PALENESS of the surface. 

PUFFIN ESS, tending to obliterate the usual depres- 
sions and prominences. 
APEX BEAT absent. 
PALPATION reveals — 

PECULIAR SENSE OF YIELDING or softness, with 
crepitation fremitus felt by the finger tips pressed 
upon the surface. 
AUSCUL TA TION. 

CREPITANT SOUNDS, myriad, fine, and somewhat 
similar to the rales in pneumonia, heard when 
the ear or stethoscope is pressed upon the surface. 



DISEASES OF THE BKONCHI, PLEUKJE, LUNGS, AND 

MEDIASTINUM. 

ACUTE AND SUBACUTE BRONCHITIS. 

Definition : inflammation of the mucous membrane lining 
the larger and medium-sized tubes of both lungs. The 
early dryness and swelling is followed by more or less 
profuse secretion. 



SIGXS IN THE DISEASES OF THE CHEST 115 

Signs. 

INSPECTION reveals little abnormal except — 
RESPIRATORY MOVEMENTS slightly accelerated. 
COUGH at first dry, harsh, with scanty secretion, later 

moist (loose), rattling. 
DYSPIMCEA rarely, except from retained secretion in 
the tubes, as in infants, the aged, or the enfeebled. 
rALBATIOX reveals — 

SURFACE TEMPERATURE and pulse slightly mod- 
ified. 
VOCAL FREMITUS normal. 

RHONCHAL FREMITUS in case of considerable secre- 
tion, especially in children, or in adults with thin 
chest-walls. 
FEB CI SSIOX. 

RESONANCE normal. 

SLIGHT DULNESS rarely, over lower part of the 
chest, due to accumulation of bronchial secretion, 
though this may be removed by expectoration. 
A USCLL TA TIOX. 

RESPIRATORY SOUNDS apt to be somewhat harsh 

over the larger tubes. 
VESICULAR MURMUR may be more or less sup- 
pressed over parts of the lungs supplied by bronchi 
partially or wholly occluded by mucus. 
VOCAL RESONANCE normal. 
ADVENTITIOUS SOUNDS. 

Dry Bales common in the first stage, slightly ob- 
scuring the vesicular murmur. 
Moist Bates (large and small) may be heard bilat- 
erally in varying numbers after the first day or 
so, with the occurrence of hypersecretion. These 
are variable in intensity, location, and time, and 
are apt to disappear upon cough, and upon deep 
inspiration or forced expiration. A few dry rales 
may occur with them. 



116 PHYSICAL DIAGNOSIS OF THE CHEST. 

CAPILLARY BRONCHITIS. 

Definition : inflammation extending from the larger to 

the smaller tubes (bronchiolitis). 
Signs. 

INSPECTION, in addition to the usual visible signs 
of acute bronchitis, reveals the age. 

AGE, young children or the aged. 

EXPRESSION of anxiety or distress common. 

CONGESTION and a more or less bloated appearance 
of the face sometimes seen. 

LIVIDITYof the face becomes more or less evident, 
both from want of proper oxygenation of the blood 
and its undue accumulation in the right heart, lead- 
ing to a fatal termination. 

AUE NASI dilated in the struggle for air. 

THE CHEST in a young child may be notably dis- 
tended at the anterior upper and middle part from 
acute compensatory emphysema, which disappears 
if recovery occurs. 

GENERAL RESTLESSNESS. 

DYSPNCEA, amounting sometimes to orthopnoea, and 

HYPERPNCEA, amounting to 60 or 70 respirations per 
minute in children. 
PALPATION. 

THE SURFACE IS HOT, and later may be covered 
with clammy perspiration. 

THE PULSE rapid, weak. 
PERCUSSION may obtain 

NORMAL RESONANCE, or 

EXAGGERATED RESONANCE over the upper lobes 
owing to emphysema, which compensates for occlu- 
sion of the many small bronchi with collapse of 
their terminal air-vesicles. 
AUSCULTATION, usually the signs of 

GENERAL BRONCHITIS of the larger tubes, and in 
addition 



SIGNS IN THE DISEASES OF THE CHEST 117 

SI Bl LANT RALES, very abundant early in the disease, 

replaced later by 
SUBCREPITAIMT RALES, both bilateral. 

CHRONIC BRONCHITIS. 

Definition : prolonged inflammation of the bronchial 
mucous membrane. This means derangement of secre- 
tion, thickening and irregularity of the surface, hyper- 
trophy of the muscular and fibrous coats, with final 
atrophy and fibrosis, eventuating in bronchiectasis, 
asthma, or emphysema. 
Signs : largely those of acute and subacute bronchitis. 
THE CHIEF CONTRAST is in the greater number 
of moist rales and the relatively few dry rales in the 
chronic affection. As the disease may tend to 
EMPHYSEMA, and frequently to more or less 
ASTHMA, the signs are correspondingly modified. 
THE ABSENCE of emaciation, pallor, tachycardia, 
hvperpnoea, and other evidences of phthisis is espe- 
cially important. 

PLASTIC BRONCHITIS. 

Definition : an acute or chronic inflammation of the bronchi, 

chiefly characterized by the exudation of fibrinous mat- 
ter, with the formation of plastic casts in the smaller, 
sometimes involving the larger tubes. 
Signs : those of ordinary bronchitis, with the evidence 
of partial or complete obstruction of some of the bronchi, 
detected by the absence or diminution of the respiratory 
sounds over the affected parts and dulness over collapsed 
lung. 

BRONCHIECTASIS. 

Definition : dilatation of the bronchial tubes with more 
or less associated bronchitis, fibrosis, and emphysema. 



118 PHYSICAL DIAGNOSIS OF THE CHEST. 

Signs. 

INSPECTION. 

DEPRESSION OF INTERCOSTAL SPACES and 
RIGIDITY OF THE CHEST-WALL, more or less 

marked, commonly unilateral. 
RESPIRATORY MOVEMENTS somewhat limited. 
COUGH with 

EXPECTORATION, usually very profuse, purulent, 
and offensive. At times more profuse in certain 
postures. 
FALFATION gives 

SIGNS VARYING greatly from time to time with the 
amount of secretion retained in the bronchiectatic 
cavities. 
Fhonchal Fremitus may be present. 
Vocal Fremitus may be abnormally increased over 
a cavity if large, and freely communicating with 
the upper air-passages ; diminished when the com- 
munication is closed. 
FEFCUSSION. 

DULNESS usual over the affected lung; most com- 
monly over the right, middle and lower lobes. It 
is sometimes removed or diminished by free ex- 
pectoration, or replaced by vesiculotympanitic, 
cracked-pot, or amphoric resonance. 
A USCUL TA TION. 

RESPIRATORY MURMURS sometimes 

Suppressed over Cavities, while respiratory sounds 

are apt to be harsh and exaggerated. 
Froncho-vesiciilar or Froncho-cavernoiis respira- 
tion may be obtained over a part after free ex- 
pectoration, where before no sounds were present. 
VOCAL AND WHISPER SOUNDS may suffer like 

changes. 
ADVENTITIOUS SOUNDS are usually present in the 
form of 



SIGXS USf THE DISEASES OF THE CHEST 119 

Rates, moist and dry, and 

Gurgles, both of which are variable in character 
and time. 

ASTHMA. 

Definition : a neurosis of the respiratory mechanism, char- 
acterized chiefly by paroxysms of dyspnoea probably 
due to spasm of the annular bronchial muscles. 
Signs during a paroxysm. 
INSPECTION. 

POSTURE, standing or sitting with elbows on the 

knees or resting upon some support. 
EXPRESSION OF ANXIETY and distress. 
NOSTRILS dilated, MOUTH open. 
PERSPIRATION profuse, commonly. 
STERNO-CLEIDO-MASTOID MUSCLES rigid and 

prominent. 
CYANOSIS of the face and neck may become very 

marked, conjunctiva? congested. 
CHEST approaches the barrel-shape or inflated type 

in cases of long standing or great frequency. 
CHANGES OF POSTURE usually very deliberate. 
RESPIRATORY MOVEMENTS restricted. 

Dyspnoea (orthopnoea) chiefly expiratory, and res- 
piration not necessarily increased in rate, but 
may be decreased. 
Inspiratory Movements short and quick. 
Expiratory Movements prolonged. 
PALPATION, MEXSUBATIOX, and PERCUS- 
SION signs not specially significant except when 
emphysema has developed. 
PULSE small, feeble, and rapid in proportion to the 
deficient aeration of the blood and overdistention 
of the right heart. 
SURFACE OF THE BODY cold and moist (clammy). 
AUSCULTATION gives 



120 PHYSICAL DIAGNOSIS OF THE CHEST. 

COG-WHEEL RESPIRATION, harsh. 
RALES. 

Dry (sonorous and sibilant). 
Chiefly in Expiration. 
Over Whole Chest* 
Obscuring' Vesicular Murmur. 
Loud enough, usually, to be heard at a distance 
from the patient (wheezing). 
Moist (large and small, subcrepitant), 

In the Later Stage in proportion to the bron- 
chitis with accompanying secretion. 

EMPHYSEMA OF THE LUNGS. 

Definition : an abnormal inflation of the lung from loss 
of elasticity, overdistention of the air-vesicles, and in 
pronounced cases more or less destruction of the alveolar 
walls by rupture, with accumulation of air in the inter- 
lobular connective tissue. 
Signs : in senile emphysema, where atrophy of the lungs 
is the chief feature, and in moderate emphysema, there 
is little change in the shape of the chest. 
INSPECTION in well-marked cases. 

FACE apt to be dusky and frequently more or less 
swollen. 
Eyes prominent and watery, conjunctivae injected. 
lips, end of Nose, and Tongue bluish. 
Nostrils dilated. 
ALONG ATTACHMENT OF DIAPHRAGM there is 
frequently a zone of dilated venous capillaries, 
though this is not peculiar to emphysema. 
POSTURE, stooping. 

STERNO-CLEI DO- MASTOIDS tense and prominent, 
NECK apparently shortened and thick, owing to the 

elevation of the sternum and shoulders. 
SHOULDERS elevated and drawn fonvard. 
FORM of the chest barrel-shaped. 



SIGNS IN THE DISEASES OF THE CHEST. 121 

General (ontour rounding out. 

Upper Bart of Sternum, 

Infra-clavicular and Mam ma ry Beg ions prom- 
inent. 

Antero-posterior Curvature of the spine increased, 
and therefore 

Antero-posterior Diameter of the chest increased. 
May be even greater than the transverse. 

Vertical Diameter apt to be decreased. 

Lower Part of Chest usually contracted, but it 
may be dilated, with a wide obtuse costal angle. 

Diter costal Sjmces wide, especially at the upper 
part of the chest. 

Supra-clavicular fossae may be deepened or shal- 
low, or bulging, especially during cough. 

Scapulce separated widely. 

Deep Transverse Depression sometimes present 
across the abdomen at the level of the twelfth 
rib, especially during expiration. 

General Emaciation. 
RESPIRATORY EXPANSION diminished. 

Breathing Chiefly Diaphragmatic. 

Bibs and Sternum move upward and forward as 
if made of one piece. 

Ditercostal Spaces and supra-clavicular fossae fall 
in markedly during forced inspiration, and bulge 
out during expiration and cough. 

False Bibs and neighboring interspaces retract 
during inspiration. 

Dyspnaa more or less persistent and exaggerated 
by attacks of bronchitis, asthma, and on ex- 
ertion. 

Inspiratory Act short and quick. 

E.rpiratory Act distinctly prolonged. 
APEX BEAT of heart not usually visible, except in 

the area of cardiac flatness ; the pulsation of the 



122 PHYSICAL DIAGNOSIS OF THE CHEST. 

enlarged right ventricle is communicated to the epi- 
gastrium through the left lobe of the liver. 
JUGULARS prominent, and sometimes pulsate. 
PALPATION. 

SKIN dry and harsh. 

VOCAL FREMITUS frequently enfeebled, but it may 

be normal or exaggerated. 
APEX BEAT rarely palpable; frequently there is a 
systolic impulse in the lower sternal and epigastric 
regions. 
MENSURATION shows the barrel 
SHAPE of the chest and 

DIMINISHED RESPIRATORY EXPANSION. 
PERCUSSION yields 

HYPER- RESONANCE, bilateral ; in exaggerated cases 

the note is high-pitched, vesiculotympanitic. 
AREA of pulmonary resonance reaches lower than 
normal, and may extend to the costal margin, less- 
ening the dulness over the heart, liver, and spleen, 
and encroaching upon or obliterating the areas of 
flatness. 
A USCUL TA TION. 

RESPIRATORY SOUNDS. 
Length. 

Inspiratory Sound delayed and shortened. 
Expiratory Sound prolonged, and may be two 
or three times as long as the inspiratory. 
Quality, Pitch, and Intensity. 

In typical cases both sounds are low in pitch, 
soft, breezy in quality, and diminished in in- 
tensity, but frequently they are harsh and 
blowing. 
ADVENTITIOUS SOUNDS. 

Dry Crackling or crumpling at the end of inspira- 
tion and beginning of expiration, supposed to be 
produced in the wall of the vesicles. 



SIGXS IN THE DISEASES OF THE CHEST. 123 

VOCAL RESONANCE is increased, diminished, or 

normal. 
HEART SOUNDS usually feeble, those at the apex 
displaced downward and to the right, sometimes 
distinct in the epigastrium. 
Pulmonary (second) sound usually distinct, and 

may be accentuated. 
Murmurs of relative tricuspid insufficiency may 

be heard when there is great dilatation of the 

right ventricle. 

ATELECTASIS. 

Definition : congenital (apneivmatosis) or acquired col- 
lapse of the lung. 
Signs. 

IXSPECTIOX usually discovers the subject a 
WEAK SICKLY INFANT. 
PALLOR or DUSKINESS of the surface. 
EMACIATION and evident great prostration. 
RESPIRATORY MOVEMENTS feeble. 

Hyperpncea, in children 60 to 80 per minute, 

common. 
Rhythm of Respiration altered, the pause follow- 
ing instead of preceding inspiration. 
Dyspnoea marked without relatively proportionate 

lividity. 
Retraetion of the Intereostal Spaees and Loner 

Ri7?s marked during inspiration. 
In the Newly-born apneumatosis is denoted 
by shallow, rapid respiration, feebleness of 
the cry, dyspnoea, especially evident in in- 
ability to nurse properly, and absence of 
cough. 
PALPATIO*. 

EXTREMITIES cold. 
PULSE feeble and rapid. 



124 PHYSICAL DIAGNOSIS OF THE CHEST. 

VOCAL FREMITUS normal or slightly exaggerated 

over the base of both lungs. 
PERCUSSION is less satisfactory in children than in 

adults. 
NORMAL RESONANCE, if the collapsed vesicles are 

so few or small and scattered as to be marked by the 

resonance of adjacent over distended lung. 
DULNESS more or less marked over the affected 

parts where of considerable area. 
AUSCUL TA TIOJST. 

VESICULAR MURMUR frequently normal where the 

percussion note remains normal. It is diminished, 

and the breathing harsh and broncho-vesicular over 

large patches of collapsed lung. 
RALES are usually numerous except in apneumatosis. 

LOBAR PNEUMONIA. 

Definition : an acute infectious disease, characterized 
locally by inflammation of the lung, clinically mani- 
fested in three stages. 
FIRST STAGE, ENGORGEMENT. 
SECOND STAGE, CONSOLIDATION (red and gray 

hepatization). 
THIRD STA GE, PROGRESSIVE RESOI UTION. 
Signs : for convenience the signs of the three stages will 
be considered under each of the methods of physical 
examination. The signs of the first stage are usually 
present within the first twenty-four hours unless the 
pneumonia is central. 
INSPECTION. 

POSTURE is often on the affected side. 
CIRCUMSCRIBED FLUSH, mahogany colored, over 

one or both cheeks. 
GENERAL PALLOR, occasionally at the onset the face 

has a dusky hue ; later sallow. 
LIPS, deep red at first, they become cyanosed with 



SIGNS IN THE DISEASES OF THE CHEST 125 

greatly disturbed circulation and pale at the 
crisis. 
HERPES labialis very frequent (50 per cent, of cases, 
Osier) ; at times herpes on cheeks, nose, and eyelids. 
SUDAMINA accompany profuse sweating. 
JAUNDICE, more or less marked, is common and an 
early sign, not apparently related to hepatic en- 
gorgement, but probably due to duodenitis. 
EXPRESSION anxious, eyes bright at first, later dull 

or expressionless. 
INTERCOSTAL SPACES not filled out as in pneumo- 

or hydrothorax. 
RAPID LOSS OF FLESH apparent in a few days. 
DELIRIUM active, violent, or low and muttering. 
SUBSULTUS TENDINUM attends the great prostra- 
tion of the " typhoid state." 
CONVULSIONS may usher in the attack in children. 
RESPIRATORY MOVEMENTS of the affected side 
restricted, markedly so in extensive consolidation 
of the lower lobe ; exaggerated movements of the 
healthy side. In double pneumonia respiratory 
movements largely diaphragmatic and inferior 
costal. 

Hyperpncea always present, 30 to 80 per minute. 
Ratio between respiration and pulse, 1 to 2 or 
even 1 to 1.5. 
Dyspnoea frequent, panting in character. 
Inspiratory Act short and superficial. 
Expiratory Act often associated with a grunt, 
especially in children. Dyspnoea depends 
upon various factors : 
Amount of lung involved, 
Rapidity of involvement, 
Fever, 
Pain, and 
Derangement of the nervous system. 



126 PHYSICAL DIAGNOSIS OF THE CHEST. 

Cough frequent, short, hacking, dry in the first 
stage, loose during resolution. 
MENSURATION may show, in the second stage, a 
very slight increase in the volume of the affected side 
during expiration. 
PALPATION discovers the 

SKIN usually hot and dry till the crisis, but it may 

be moist from the onset (a favorable sign). 
PRESSURE may elicit deep-seated tenderness. 
VOCAL FREMITUS in the 

First Stage is not affected ; in the 
Second Stage, greatly increased over the consolida- 
tion, unless this be central or pleuritic effusion 
covers it, or the large and medium-sized bronchi 
become blocked (massive pneumonia); or if 
there is complicating bronchitis with free secre- 
tion. 
Third Stage, progressive return to the normal 
type. 
FRICTION FREMITUS maybe obtained in some cases 

owing to accompanying pleuritis. 
LOCATION OF APEX BEAT may show the heart 

slightly displaced away from the affected side. 
PULSE, 
Rapidity. 

In Mild Cases, from 90 to 120. 
In Severe Cases, from 120 to 160. 
In Children, 100 to 200. 
Volume and Tension. 
At Onset it is full, bounding. 
After the Third or fourth day it becomes com- 
pressible, small, weak, and may be dicrotic 
and intermittent in unfavorable cases. 
In Old Age the radial pulse is not reliable, and 
the pulse should be taken at the apex beat. 
PERCUSSION. 



SIGNS IN THE DISEASES OF THE CHEST. 127 

FIRST STAGE. 

Dulness increasing at the end of the first stage ex- 
cept in central pneumonia. The note may some- 
times be vesiculo-tympa nitic. 
SECOND STAGE. 

Marked Dulness over the consolidation with a 
sense of resistance to the pleximeter finger, less 
than in pleurisy with effusion. 
Hyper-resonance over the healthy parts. 
Tympanitic Note occasionally, 

Over Healthy Lung* adjacent to consolidation. 
Over a Consolidated Upper Lobe due to con- 
duction of resonance from the trachea and 
main bronchi. 
Cracked-pot Note occasionally over relaxed lung 
adjacent to the consolidation. 
THIRD STAGE. 

Dulness slowly diminishing with progressive reso- 
lution ; normal resonance established only after 
weeks. 
A USCUL TA TION. 

RESPIRATORY SOUNDS are — 

Early in the First Stage feeble, and apt to be dry 

ancj somewhat harsh over the affected part. 
Later it becomes broncho-vesicular. In the 
Second Stage. 

Bronchial Breathing*, provided the large bronchi 

are patulous. 
Exaggerated Breathing- over the healthy lung. 
Third Stage. 

Breathing becomes broncho-vesicular, approach- 
ing the normal. 
VOCAL SOUNDS. 
First Stage normal. 
Second Stage. 

Bronchophony and frequently 



128 PHYSICAL DIAGNOSIS OF THE CHEST, 

Pectoriloquy are characteristic of complete con- 
solidation. 
^aUgophony not uncommon about the upper level 
of the fluid if little pleuritic effusion accom- 
pany the consolidation, voice sounds being ab- 
sent or indistinct below. 
Third Stage. 

Bronchophony and Pectoriloquy give place to 
exaggerated vocal resonance approaching the 
normal sounds. 
ADVENTITIOUS SOUNDS. 
First Stage. 

Crepitant Rales, lasting usually from 12 to 24 
hours. These may be 
Absent. 

(1) If stages follow each other rapidly. 

(2) In pneumonia complicating rheumatism. 

(3) In lobes secondarily attacked. 

(4) They are absent oftener in pneumonia 
of children than in adults. 

Second Stage. 

Subcrepitant Rales may or may not be present. 
Third Stage. 

Crepitant Rales return, u crepitant rale redux," 

but are largely obscured by the coarser 
Subcrepitant Rales, which are frequently accom- 
panied by a few dry rales and more or less 
large mucous rales. 

LOBULAR OR BRONCHO-PNEUMONIA. 

Definition : this is essentially an inflammation of termi- 
nal bronchi, with their branches and surrounding air- 
vesicles, which make up the pulmonary lobules. It 
occurs in the course of bronchitis, extending to the 
finer tubes, and is manifested in isolated or in groups of 
lobules. These show interstitial inflammation of both 



SIGNS IN THE DISEASES OF THE CHEST 129 

tubes and air-cells, both being filled with a muco- 
purulent secretion. 
Signs : these are not distinctive unless there is considera- 
ble consolidation, and even then rarely sufficient for 
diagnosis without the aid of history and symptoms. 
IJSSrECTIOX shows the patient usually 
AN INFANT or in ADVANCED AGE. 
FACE PALE and ANXIOUS, becoming CYANOTIC in 

severe cases. 
EMACIATION very rapid. Chest bilaterally retracted 
at the lower part, where there is extreme pulmo- 
nary collapse in children. 
DYSPNCEA marked. 

Inspiration often shortened and 
Expiration lengthened. 
HYPERPNCEA constant. 

RESPIRATORY MOVEMENTS DEFICIENT. 
Slight expansion of the ribs. 

Elevation of the chest-wall at the upper part, and 
retraction of the soft parts and lower ribs on 
inspiration. 
COUGH dry, hacking, non-paroxysmal, painful. 
RESTLESSNESS and jactitation in children gives 
place to lethargy with advancing consolidation and 
obstruction of the bronchi. 
PALPATIOX may elicit 

VOCAL FREMITUS, slightly increased over small 

areas, where neighboring lobules are consolidated. 
PULSE often reaches 140 to 150 per minute; small, 
compressible, feeble after the first twenty-four 
hours. 
PERCUSSION. 

DULNESS more or less marked, but in patches usually, 
bilateral and limited to the posterior and lower 
regions of the chest ; sometimes unilateral. 
HYPER-RESONANCE over upper and anterior part 



130 PHYSICAL DIAGNOSIS OF THE CHEST. 

of chest where functional emphysema occurs in the 
corresponding part of the lungs. 
A TJSCULTATION. 

VESICULAR MURMUR feeble. 

BRONCHO-VESICULAR and bronchial respiration. 

VOCAL FREMITUS exaggerated. 

RALES, moist and high-pitched over the lower part 
of the chest, irregular in time and place. 

UNDEFINED MUCOUS CLICKS, on forced respira- 
tion. Signs of emphysema are frequently found over 
the anterior and upper part of the chest. 

PULMONARY TUBERCULOSIS. 

Definition : this affection is extremely varied in its pri- 
mary location and manner of development, and there- 
fore needs a few words of introduction. 

It is characterized etiologically by the entrance 
of tubercle bacilli into the lungs with the respired 
air or through the lymphatic or blood-vessels. 
Pathologically, therefore, the initial tubercle 
may result early in (1) bronchial ulceration, or 
the initial lesion may be in the small tubes of 
one or more lobules, giving the usual early catar- 
rhal signs of (2) tubercular bronchiolitis, as so 
often manifested at one or the other apex, and 
followed pari passu by the signs of consolida- 
tion as the neighboring vesicles become involved. 
Again, sudden rupture of a bronchial lymphatic 
gland or other tuberculous focus, with aspiration 
of its infectious contents into the bronchi of 
many lobules, may result in rapidly developing 
(3) caseous pneumonia, involving more or less 
of one lobe. Finally, the entrance of a large 
number of tubercle bacilli into the circulation, 
from a primary systemic focus, and their wide 
dissemination in the lung (as well as in many 



SIGNS IN THE DISEASES OF THE CHEST 131 

other organs), results in (4) acute miliary tuber- 
culosis, the pulmonary signs of which are insig- 
nificant. 

The morbid conditions which may appear in the 
course of pulmonary tuberculosis, more or less 
slow in its progress, are tubercular bronchitis, 
lobular and lobar consolidation, the formation 
of cavities, compensator}' emphysema, fibrosis 
and calcification, bronchiectasis, oedema, collapse, 
and pleuritis, with or without effusion or pneumo- 
thorax. 
Signs of pulmonary tuberculosis, beginning as a broncho- 
pneumonia. 
IXITIAL OR CATARRHAL STAGE before the 

advent of consolidation. 
INSPECTION. 

Color and Nutrition may not be much affected. 

Flat or "Alar Chest" more or less marked in 
many cases. 

No Abnormal Local Retraction of the chest as vet. 

Respiratory Expansion of one or the other apex 
may be slightly deficient or apparently lagging 
as compared to the other. 

No Hyperpncea as yet. 
PALPATION and mensuration negative, or 

Raise rate slightly increased, and 

Respiratory Expansion deficient at one apex. 
PERCUSSION negative. 
AUSCULTATION. 

Respiratory Murmur frequently feeble, having 
interrupted or cog-wheel rhythm, and accom- 
panied by 

Subcrepitant Rales, which may be feeble, few, 
and distant at an early stage, but become more 
distinct. Later and sometimes early the respira- 
tory murmur may be harsh, occasionally there are 



132 PHYSICAL DIAGNOSIS OF THE CHEST. 

A Few Sibilant Males. 

A Mucous Click or friction or indistinct crumpling 
sound may be heard. 
STAGE OF CONSOLIDATION (tuberculosis). 

INSPECTION yields, in addition to the signs of the 
first stage, 

Fallor and Emaciation. 

Hectic Flush, and frequently very red lips. 

Tenia Versicolor, common on the surface of the 
thorax and other parts. 

Retraction of the supra-clavicular and infra- 
clavicular region at the affected apex. 

Hyperpncea, superficial breathing and a tendency 
to cough on deep inspiration. 

Apeoo Beat enlarged in area and abnormally rapid. 
PALPATION. 

Skin hot and dry, or apt to be bathed in perspira- 
tion. 

Mespiratory Movements diminished. 

Vocal Fremitus increased over consolidation. It is 
normally greater at the right apex than the left. 
Vocal fremitus may be diminished if the pleura 
is greatly thickened over the consolidated lung. 

Fulse rate usually above a hundred. 
PERCUSSION. 

Dulness above and over the clavicle, or in the 
supra-scapular region, early ; proportionately 
more extensive with the advance of consolida- 
tion. The two apices should be percussed while 
the patient holds his breath after full inspira- 
tion, especially to elicit the presence of but slight 
dulness. 
Dulness corresponds to the consolidation in any 

part of the lung. 
Deep-seated consolidation with overlying normal 
lung may not be detected. 



SIGNS IN THE DISEASES OF THE CHEST. 133 

A small portion of superficial consolidation, with 
underlying and surrounding overdistended 
lung, may not be easily detected. 
Dulness in any case may be in part due to the 
simple acute pneumonia surrounding tuber- 
cular consolidation, which may clean up, leav- 
ing only the smaller area of dulness due to 
the tubercular part. 
Tympanitic Resonance at times may be obtained 
over consolidation adjacent to the trachea. 
AUSCULTATION. 

Respiratory Sounds are apt to be harsh and 
broncho- vesicular or purely bronchial, according 
to the amount of consolidation. 
Whisper and Vocal Resonance are apt to be ex- 
aggerated and bronchial. The latter amounts to 
pectoriloquy when the consolidation surrounds a 
large bronchus. 
Heart Sounds are apt to be exaggerated over neigh- 
boring consolidation, and the second pulmonic 
sound is frequently accentuated. 
Adventitious Sounds are more or less numerous. 
Rales large and small, dry and moist, often pe- 
culiarly sticky in character. 
Friction Sounds are often present, due to cir- 
cumscribed pleuritis. 
STAGE OF THE FOR3IATION OF CAVITIES. 
INSPECTION shows usually — 

Fronounced Anmmia and Emaciation, and in 
exaggerated cases signs of poor circulation, such 
as local cyanosis of lips, nose, and extremities. 
Clubbing of the Fingers. 

Face is apt to bear the impress of prolonged 
wasting illness, drawn haggard expression (ex- 
ceptionally cavities may be formed in cases 
apparently healthy). 



134 PHYSICAL DIAGNOSIS OF THE CHEST. 

Marked Depression of the chest from retraction 
of the affected lung. 

Respiratory Movements limited, on the affected 
side and abnormally rapid. 

Apeao Beat rapid, weak, and frequently displaced 
toward the affected side. 
PALPATION. 

Vocal Fremitus increased over a cavity if empty 
and freely communicating with a bronchus. 

Rhonehal and Friction Fremitus commonly 
present. 

False small, compressible, feeble, and rapid. 
PERCUSSION in the stage of cavities (see also pages 
68 and 69). 

Dulness of consolidation is modified by the res- 
onance of a cavity. 

Amphoric or Cracked-pot Resonance when a 
cavity communicates more or less freely with a 
bronchus. The resonance disappears with the 
filling of a cavity with fluid. Sometimes even 
a large cavity communicating freely with a 
bronchus gives dulness or cracked-pot resonance 
when the patient's mouth is closed, but marked 
amphoric resonance with the mouth open (see 
Wintrich's change of sound, p. 69). 

Small cavities deeply located are not easy and are 
often impossible to locate by percussion. 

Numerous Isolated Cavities at the apex without 
much fibrosis or pleuritic thickening may give 
resonance not far from the normal vesicular res- 
onance, in contrast to the auscultatory signs. 
AUSCULTATION in the stage of cavities when the 
cavity is empty and freely communicates with a 
bronchus. 

Respiratory Sounds. 

Cavernous Respiration, soft blowing or puffing 



SIGNS IN THE DISEASES OF THE CHEST. 135 

in character, the expiratory sound prolonged 
and low-pitched. 
Broncho-cavernous Respiration, when the cav- 
ity is not large and is surrounded by consoli- 
dation. 
Amphoric Respiration, which is more metallic 
and resonant than cavernous respiration, is 
heard in exceptional cases. 
Vocal and Whispering Sounds correspond in 
change to the respiratory sounds. Vocal res- 
onance amounts to pectoriloquy. If the cavity 
is filled with fluid or its opening closed none of 
these sounds may be heard. 
Adventitious Sounds. 

Rales, dry and moist and gurgling. 
Metallic Tinkling', occasionally. 
In most cases of advanced phthisis the pulmonary 
signs of all three stages may be present, de- 
pending upon the pathological condition of 
the part. 

FIBROID PHTHISIS. 

Definition : a chronic inflammatory affection of the lung 
characterized pathologically by more or less hyperplasia of 
the peribronchial, inter-alveolar, and inter-lobular con- 
nective tissue and pleura, which in contracting encroaches 
upon the lumen of vessels and air-passages. The fibrosis 
is accompanied by degenerative processes and often by 
tuberculosis. The signs in a typical case are, therefore, 
out of proportion to the relatively mild symptoms, which 
are those of chronic bronchitis. 
Signs. 

IXSrECTIOX may reveal— 

NUTRITION and COLOR but little changed. 
FLATTENING OR RETRACTION of the chest-wall 
over the affected side. 



136 PHYSICAL DIAGNOSIS OF THE CHEST. 

DEPRESSION OF THE CORRESPONDING SHOUL- 
DER, influencing posture. 

DYSPNCEA may or may not be apparent. 

COUGH frequent and variable. 

RESPIRATORY MOVEMENTS limited on the affected 
side ; increased on the opposite side except late in 
the case, after the unaffected lung has become em- 
physematous. 

HEART dislocated toward the contracted lung, as 
evidenced by the apex beat. 
PALPATION frequently elicits — 

EXAGGERATED VOCAL FREMITUS over the con- 
tracted lung, though the greatly thickened pleura 
and contracted bronchi may diminish vocal fremitus 
in some cases. 

PULSE more or less rapid according to the inter- 
ference with respiration or the amount of infection 
or fever present. 
PERCUSSION gives— 

DULNESS over the affected part, 

EXAGGERATED RESONANCE on the sound side, fre- 
quently extending across the mid-sternal line and 
to the limits of the pleural cavity (to the costal 
arch) below. 
AUSCULTATION gives— 

BRONCHIAL BREATHING and BRONCHOPHONY, 
and frequently feeble respiration on the affected 
side. Vesicular murmur absent, 

EXAGGERATED OR NORMAL breathing on the 
sound side. 

VOCAL RESONANCE more or less bronchial over 
the affected side. 

ADVENTITIOUS SOUNDS variable. 

RALES dry or moist are common. 



SIGNS IN THE DISEASES OF THE CHEST 137 

PULMONARY HYPER/EMIA. 

Definition : excess of blood in the pulmonary vessels 

(active or passive). 
Signs not distinct, apart from sudden dyspnoea and other 
signs of pulmonary oedema. 

PULMONARY CEDEMA. 

Definition : a serous transudate into the vesicular and 
interstitial tissues of the lung. It usually affects the 
most dependent parts of the lungs. 
Signs. 

INSPECTION and PALPATION. 
CYANOSIS. 
HYPERPNCEA. 

DYSPNCEA (sudden in occurrence). 
COUGH with frothy sputum. 

SIGNS OF GENERAL DROPSY and its causative 
disease, such as anaemia, cardiac disease, or scor- 
butus, may be present. 
PERCUSSION. 

DULNESS over the lower portion of one or both 
lungs. 
A USCULTA TION. 

RESPIRATORY MURMUR vesicular or slightly bron- 
cho-vesicular, but feeble. 
RALES abundant, fine, subcrepitant, usually heard 

both in expiration and inspiration. 
VOCAL RESONANCE normal, or it may be slightly 

increased. 
PULMONIC SECOND SOUND is apt to be accen- 
tuated. 

PULMONARY HEMORRHAGE. 
Bronchial Hemorrhage. 

DEFINITION: hemorrhage from the wall of a 
bronchial tube or the trachea. 



138 PHYSICAL DIAGNOSIS OF THE CHEST. 

SIGNS: often none at all, except cough and haemopty- 
sis. During hemorrhage and for hours following 
it, may be found 
RALES large and small, moist in character, over the 

same part of the chest, and 
FEEBLE RESPIRATION and perhaps slight dulness. 
Pulmonary Apoplexy. 

DEFIJS IT ION : extravasation of blood from a rup- 
tured vessel into the lung tissue. It is rare, and 
usually occurs in the lower lobes. 
SIGNS. 

INSPECTION usually reveals if the hemorrhage is 
large. 
Dyspnoea with cough and hcemoptysis. 
PALPATION practically negative. 
PERCUSSION. 

Dulness more or less extensive unless the patches 
of hemorrhagic infarcts are few and small or 
deeply seated. 
AUSCULTATION reveals— 
Early, 

Rales, moist, large and small, and possibly crepi- 
tant in the region of the hemorrhage, previous 
to coagulation. 
Later, after coagulation, the 

Respiratory Murmur is apt to be feeble or 
suppressed, especially with the blocking of a 
bronchus of large size. 
Bronchial Breathing' and Voice may be more 
or less marked in some cases. 

PULMONARY THROMBOSIS AND EMBOLISM. 
Definition. 

PULMONARY THROMBOSIS is a gradual ob- 
struction of a pulmonary artery (venous radical) or 
one of its branches by a clot formed in situ. 



SIGNS IN THE DISEASES OF THE CHEST 139 

PULMONARY EMBOLISM is a sudden blocking 
of a pulmonary vein or bronchial artery by a foreign 
body, usually a fragment of a vegetation from a car- 
diac valve or a fragment of a thrombus from some 
of the systemic veins. 
Signs. 

INSPECTION and PALPATION may reveal dys- 
pnoea, cyanosis, and rapid heart, and possibly pulsa- 
tion of the jugulars. 

PERCUSSION may elicit exaggerated resonance over 
the depleted area resulting from increase of air in the 
cells corresponding to the decrease of the blood in 
their walls. 

A ISC UL TA TION. 

RESPIRATORY MURMUR feeble or suppressed in 
the same area. 

PULMONARY ABSCESS. 

Definition: a circumscribed collection of pus within the 

lung. 
Signs. 

INSPECTION may reveal — 

PALLOR, EMACIATION, and evidences of pyrexia 

and prostration. 
DEPRESSION OF THE CHEST-WALL may be 
present, with atrophy of the intercostal muscles 
over a cavity where this is large and super- 
ficial. 
DYSPNCEA, COUGH, and sometimes marked bulging 
of the intercostal spaces over the cavity during 
cough. 
PALPATION. 

VOCAL FREMITUS. 
Decreased at first, and 

Increased over the cavity when large, superficial, 
and freely communicating with a bronchus. 



140 PHYSICAL DIAGNOSIS OF THE CHEST. 

PERCUSSION. 

DULNESS circumscribed or general in case of pneu- 
monia, giving place to tympany over the cavity if 
of sufficient size (see p. 68). 
AUSCVL TA TIOJST. 

RESPIRATORY MURMUR feeble or absent, or some- 
times bronchial over the abscess. 

INDISTINCT RALES, and after escape of the pus the 

SIGNS OF A CAVITY. 

PULMONARY GANGRENE. 

Definition : necrosis of lung-tissue, accompanied by de- 
composition. It may occur in one or more sharply 
defined foci, varying from the size of a pea to that of a 
hen's egg, usually in the periphery of the lower lobe. 
More rarely it is diffuse, involving more or less of one 
lobe or the whole of one lung. 
Signs are not distinctive, as the same may be present in 
other forms of phthisis. 

The odor of the breath is well-nigh pathognomonic. 
INSPECTION. 
COUGH. 

Temporary in circumscribed gangrene. 
Persistent in the diffuse form. 
HYPERPNCEA largely in proportion to the amount 

of lung involved. 
CIRCUMSCRIBED DEPRESSION of the chest-wall 
toward recovery. 
PALPATION. 

VOCAL FREMITUS normal, absent, or increased. 
PERCUSSION. 

DULNESS or flatness over the gangrenous foci, and 
surrounding consolidation if sufficiently extensive. 
AMPHORIC OR CRACKED -POT resonance with the 
formation of cavities in case the patient survive. 
AUSCUL TA TION. 



SIGXS IN THE DISEASES OF THE CHEST 141 

RESPIRATORY MURMUR absent, or feeble bronchial 
breathing over the foci, largely dependent upon the 
openness of the corresponding larger tubes. 

AMPHORIC or CAVERNOUS RESPIRATION, with 
the formation of cavities, if freely communicating 
with a large bronchus. 

ADVENTITIOUS SOUNDS. 

Bales moist in character are apt to be present. 
Gurgling Sounds with the formation of cavities. 

PULMONARY CANCER. 

Definition : sarcoma or carcinoma of the lung rarely 
primary, and when secondary either involving the part 
by contiguity from primary affection of neighboring 
organs, as the oesophagus and liver, or metastasis, as 
emboli from a distant focus. 
Signs : these vary with the character, extent, and location 
of the tumor. The signs may be those of bronchitis, 
pneumonia, or tuberculosis in any of its stages. Nodular 
cancer may give few or all of the following : 
IXSPECTIOX. 

CACHEXIA evident. 

LOCAL enlargement of superficial veins. 

RETRACTION of the chest-wall, depending upon col- 
lapse of the lung. 

BULGING or fulness when the tumor is large or ac- 
companied by pleuritic effusion. 
PALPATIOX. 

VOCAL FREMITUS feeble or absent. 
PEBCLSSIOX. 

DULNESS or flatness over the lung, or possibly nor- 
mal resonance surrounded by dulness. 
A ISC UL TA TIOX. 

RESPIRATORY SOUNDS feeble or possibly bronchial. 

VOCAL SOUNDS feeble, sometimes bronchophony. 

ADVENTITIOUS SOUNDS, rales, etc., variable. 



142 PHYSICAL DIAGNOSIS OF THE CHEST. 

ENLARGED BRONCHIAL GLANDS. 

Definition : enlargement of the lymphatic glands which 
lie at the bifurcation of the trachea and about the main 
bronchi is rare as an independent disorder, and is chiefly 
of interest as a local manifestation of tuberculosis or 
malignant growths or syphilis. 
Signs. 

INSPECTION. 

EMACIATION and hectic flush and other visible evi- 
dences of tuberculosis may be present. 
CERVICAL VEINS may be distended. 
CYANOSIS present when there is marked pressure 

upon large venous radicles. 
RESPIRATORY MOVEMENT deficient on one side as 

a result of pressure upon a main bronchus. 
COUGH dry, ringing, paroxysmal, a common sign. 
DYSPNCEA common. 
TAITATION. 

TENDERNESS in the inter-scapular region near the 
fourth or fifth rib is occasionally present. 
PERCUSSION. 

DULNESS over the glands when they are greatly en- 
larged. Dulness uniform over one side may result 
from pulmonary collapse from occlusion of the 
main bronchus. 
AUSCULTATION usually discovers — 

MURMURS, arterial and venous, from pressure upon 

corresponding vessels. 
RESPIRATORY SOUNDS feeble or absent on one 
side, owing to pressure on the main bronchus. 
Deep respiration may develop sounds not present 
in ordinary respiration. 
VOCAL SOUNDS also diminished for the same reason. 
ADVENTITIOUS SOUNDS, rales are apt to be present 
owing to the secretion within the tubes as a result 
of bronchitis. 



SIGNS IX THE DISEASES OF THE CHEST. 143 

HYDATID CYSTS OF THE LUNG. 

Rare, usually secondary to hydatids of the liver. Signs 
fairly distinct when the cysts are large. 
Signs. 

INSPECTION. 

DECUBITUS upon the sound side. 

SLIGHT BULGING of the intercostal spaces over the 

cyst, and possibly slight 
ENLARGEMENT of the affected side. 
RESPIRATORY MOVEMENT limited on the affected 
side and increased on the sound side. 
FALFATIOX. 

VOCAL FREMITUS absent over the cyst. 
FLUCTUATION may sometimes be detected when the 
cyst is large and superficial. 
FEBCZSSIOX. 

DULNESS or flatness circumscribed over the cyst, sur- 
rounded by resonance. Dulness unchanging with 
posture of patient. 
A LSCLL TA TIOX. 

RESPIRATORY MURMUR absent over areas of flat- 
ness, normal or slightly broncho-vesicular imme- 
diately around it. 

PLEURISY, acute, subacute, and chronic. 

Definition : an inflammation of the pleura, characterized 
locally by early dryness of the pleuritic surfaces, fol- 
lowed by the exudation of fibrinous lymph and more or 
less fluid. The latter is attended by proportionate com- 
pression of the lung, displacement of the organs, and 
interference with normal functions. There may be more 
or less complete resolution or crippling of the lung by 
thickening of the pleura and adhesions, with permanent 
disarrangement of normal organic relations. 

Signs. 

AT THE OXSET of an attack. 



144 PHYSICAL DIAGNOSIS OF THE CHEST. 

INSPECTION. 

Posture usually on the sound side to relieve pres- 
sure from the inflamed pleura. 
Hyperpnwa due to 
Fever, or in 

Compensation for shallow respiration. 
Limited Movement (slight) on the affected side to 

avoid pain. 
Increased Movement on the sound side. 
PALPATION may elicit — 

Friction Fremitus on the affected side. 

Surface Temperature possibly higher on affected 

side. 
Tenderness or pain upon deep pressure on affected 
side. In diaphragmatic pleurisy pain may be 
elicited at the tenth rib at the insertion of the 
diaphragm. 
PERCUSSION negative except for the production of 

pain. 
AUSCULTATION. 

Vesicular Murmur on the affected side. 
Diminished in intensity and duration owing to 

the restrained respiratory movements. 
Rhythm Disturbed, jerky, cog-wheel. 
Friction Sounds. 
Pleuritic. 

Area circumscribed or diffused. 
Time, with inspiration and expiration, but 
most marked in the former and broken and 
jerky in rhythm. 
Character, superficial and fine, grazing or 
coarse, creaking; or grating, rasping, or 
sawing in sound. 
Pleuro-pericardiac Friction Sounds. 

Area usually most distinct at the apex 
or along the right or left border of the 



SIGNS IN THE DISEASES OF THE CHEST. 145 

heart, where the pleurisy is adjacent to the 
heart. 
Time, synchronous with the heart's motion, 
and accompanied by others (coarser) during 
respiration. 
Character, usually line, grazing. 
Bronchial Bales from coexisting bronchitis (in- 
cidental). 
WHEN THE BE IS MODERATE EFFUSION— 
e. g., at the level of the fifth rib in front, not suf- 
ficient to markedly displace organs or change con- 
tour of the thorax. 
INSPECTION. 

Posture on either side or back. 
Respiratory Movement limited on the affected 
side, now due in part to compression of the lung. 
Hyperpnoea and perhaps dyspnoea. 
PALPATION. 

Restricted Respiratory Movements* 
local Fremitus enfeebled over the effusion. 
MENSURATION. 

Slight loss of respiratory expansion. 
PERCUSSION. 

Beginning Dulness over the fluid, first noticeable 

in the infra-scapular and infra-axillary regions. 
Dulness just below the level of the fluid merging 

into flatness below. 
Elasticity wanting as felt by the pleximeter finger. 
Upper line of Dulness not horizontal in the erect 
posture, but highest in the axillary region, de- 
scending in front and behind, forming the letter 
S curve posteriorly. 
Slight Change in level takes place slowly in change 
from the erect posture to recumbency, and vice 
versd, where no limiting adhesion exists above 
the effusion. 
10 



146 PHYSICAL DIAGNOSIS OF THE CHEST. 

AUSCULTATION. 

Respiratory Sounds feeble and distant or absent 
over the fluid, except in children, where they 
may be distinctly broncho- vesicular. 
Immediately Above the level of the fluid re- 
spiratory sounds are exaggerated or broncho- 
vesicular and harsh. 
Over the Sound Lung exaggerated respiratory 
sounds corresponding to increased function. 
Vocal Resonance. 
Over the Fluid, diminished or absent. 
At the Upper Border of the fluid occasionally 

segophony may be heard. 
Elsewhere normal. 
WHEN THE EFFUSION IS LARGE IN 
AMOUNT. 
INSPECTION. 

Fosture, usually on or toward the affected side to 

give the unobstructed lung free play. 
Tailor, from anaemia, and 

Emaciation usually present, not necessarily marked. 
Cyanosis of the lips, chin, end of nose, and tips 

of extremities not infrequent. 
Unilateral Enlargement of the chest on the af- 
fected side, especially the lower half. 
Nipple and Scapula farther from the median 

line. 
Shoulder elevated. 
Lower Intercostal Spaces widened and filled out, 

rarely bulging. 
Hypochondrium prominent on the affected side, 

especially if this be the right. 
Hyperpnoea, and usually dyspnoea, very marked 

on slight exertion. 
Respiratory Movements markedly restricted on 
the affected side, increased on the sound side. 



SIGNS IN THE DISEASES OF THE CHEST. 147 

Apex Beat displaced to the right or left away from 
the effusion. 
PALPATION in large pleuritic effusion. 

Restricted Movement and Enlargement of the 

affected side. 
Intercostal Spaces widened and filled out. 
A Sense of Fluctuation sometimes obtained by 
applying the finger to the intercostal spaces and 
making percussion on the opposite aspect of the 
affected side. 
Vocal Fremitus absent over the fluid, except in 
children, where it may be present over effusions 
of considerable size. It may be conducted 
through the effusion along the line of an exten- 
sive adhesion or band. Posteriorly it may some- 
times be conducted for some distance over the 
effusion from the sound side by the chest-wall as 
a medium. 
Apex Beat displaced. . 

Pulse accelerated, small in volume, low in tension, 
especially in large effusions of the left side. It 
is apt to be irregular in both time and force. 
Tender Points of intercostal neuralgia not infre- 
quently present. 
MENSURATION. 

Enlargement and loss of movement on the affected 
side. 
PERCUSSION in large pleuritic effusion. 

Flatness over a large part of the affected side. 
In the Largest Effusions all resonance disap- 
pears except over a limited area (dulness) in 
the upper inter-scapular region, over the com- 
pressed lung. Flatness may extend across the 
sternum, encroaching on the opposite lung. 
In Right-sided Effusions the liver dulness is de- 
pressed, sometimes depressed even to the navel. 



148 PHYSICAL DIAGNOSIS OF THE CHEST. 

In Left-sided Effusions flatness extends to the 

margin of the ribs, masking the spleen or 

depressing it in the abdomen, and obliterating 

stomach tympany in the so-called semilunar 

space of Traube. 

Vesiculotympanitic note may be present in the 

supra-scapular and supra-clavicular region 

(Skoda). This is owing to a loss of pulmonary 

tension, or to vesicular emphysema, or possibly 

to the formation of vapor in the pleuritic space. 

Cracked-pot resonance sometimes in infra-clavicular 

region. 
Cardiac Dulness may be found to the right of 
the sternum. 
AUSCULTATION in large pleuritic effusion. 

Respiratory and vocal sounds wholly absent over 
the affected side, except feeble bronchial sounds 
in the inter-scapular region over the compressed 
lung. These are absent in extreme cases. 
Whisper Resonance sometimes distinct over sero- 
fibrinous effusions, but absent over pus (Baccelli). 
Position of Heart can frequently be made out by 
the relative distinctness of its sounds, when its im- 
pulse is invisible and cardiac dulness uncertain. 
Systolic Murmurs may be heard over the heart, 
which disappear after aspiration or absorption 
of the effusion. 
AFTER RESORPTION OF THE EFFUSION 
when the effusion has been long present. 
INSPECTION. 

Affected Side shows — 

Circumscribed Depressions or more general 

retraction. 
Displacement of the Intra-thoracic organs by 
retraction of the lung and fibrous pleuritic ad- 
hesions. 



SIGXS TN THE DISEASES OF THE CHEST. 149 

Shoulder lowered on the affected side. 
Intercostal Spaces narrow. 
Scapulae may project in a wing-like manner. 
Spinal Column, scoliosis toward the sound side. 

Sound Side shows exaggerated normal condition. 
PALPATION. 

Apex Beat displaced. 

Vocal Fremitus exaggerated, or diminished when 
the main bronchi are contracted or the pleura 
is greatly thickened. 

Pulse, normal in rate and force where the contracted 
lung has not become tubercular. 
PERCUSSION. 

Dulness over the contracted lung. 

Hyper-resonance over the sound lung, which may 
extend across the mid-sternal line even to the 
parasternal line. 
AUSCULTATION. 

Hespiratory Sounds diminished on the affected 
side and more or less bronchial. On the sound 
side respiratory sounds exaggerated, or dimin- 
ished and vesicular when emphysema has devel- 
oped. 

PNEUMOTHORAX and PNEUMO-HYDROTHORAX. 
Definition : an accumulation of air or other gases outside 
the lung in the pleural cavity. The lung, unless bound 
by adhesions, retracts and finally exists as a collapsed^ 
nearly airless, fleshy mass at the upper and back part 
of the chest-cavity. There comes to be more or less 
fluid, serous or purulent, at the lower part of the cavity 
(pneumo-hydrothorax or pneumo-pyothorax). 
Signs. 

INSPECTION. 

PALLOR and EMACIATION characteristic of advanced 
phthisis. 



150 PHYSICAL PI A GNOSIS OF THE CHEST. 

CYANOSIS may be marked when perforation oc- 
curs. 

ENLARGEMENT of the affected side. 

INTERCOSTAL SPACES wide and full, or bulging, 
and do not recede on inspiration. 

HYPERPNCEA and DYSPNCE A amounting to ortho- 
pnea, especially at the line of perforation. These 
may subside except on exertion. 

RESPIRATORY MOVEMENT lost on the affected side, 
increased on the sound side. 

APEX BEAT displaced usually to the opposite side of 
the chest. 
PALPATION. 

VOCAL FREMITUS, feeble or absent over the affected 
side. 

SUCCUSSION FREMITUS when present, characteristic 
of pneumo-hydrothorax. 

PULSE feeble and rapid. 
MENS UK A TION. 

ENLARGEMENT OF THE AFFECTED SIDE. 
PERCUSSION. 

OVER THE AIR more or less tympany, varying in 
pitch according to the amount of air present and 
the degree of tension. Amphoric resonance when 
a large opening communicates with a bronchus. 
When the air is under great tension, as in cases 
where the opening has a valve-like action, the per- 
cussion note may be positively dull. 

OVER THE FLUID flatness at the lower part of the 
chest according to the amount present. The upper 
line is horizontal and straight, and changes with 
the posture of the patient. 

OVER THE SOUND SIDE hyper-vesicular resonance. 
AUSCUL TA TION. 

RESPIRATORY and VOCAL SOUNDS. 
Over the Air vesicular murmur absent. 



SIGXS IN THE DISEASES OF THE CHEST. 151 

Respiratory, Vocal and Whisper Sounds when 
present are amphoric, but may be feeble. All 
respiratory and vocal sounds are absent if the 
opening into a bronchus is closed. 

Over the Flit id they are absent. 

Over the Compressed Limy, at the upper inter- 
scapular region. Respiratory and vocal sounds 
are feeble, but bronchial when present at all. 

Over the Sound Side puerile respiration. 
ADVENTITIOUS SOUNDS. 

Bales when present over the affected side are me- 
tallic in character. 

Metallic Tinkling when fluid drops from the upper 
part of a cavity into the fluid ; it may also be due 
to the bubbling of air through the fluid when 
it rises above the mouth of the opening into a 
bronchus. 

Succussion splashing sounds, upon agitation of the 
fluid by shaking the body, have a metallic quality. 

Bell or Coin Sound is produced as the ear is ap- 
plied to one aspect of the affected side while per- 
cussion is made by two coins used as plexor and 
pleximeter (see page 89). 

FALSE PNEUMOTHORAX. 

Definition : the term has been applied to subdiaphragmatic 
air-containing abscess cavities, usually on the right side, 
between the liver and diaphragm, occasionally on the 
left. They originate from perforating ulcers in the wall 
of the stomach or duodenum. 

Signs of a limited pneumothorax are sometimes present. 

DIAPHRAGMATIC HERNIA gives signs similar to those 
of pneumothorax, such as 
Evidence of Displaced Heart and compressed lung. 
Tympanitic Resonance. 



152 PHYSICAL DIAGNOSIS OF THE CHEST, 

Respiratory Sounds absent. 

Metallic Tinkling may be absent. 

Sudden Disappearance or advent of signs due to return 

of the bowel to the abdominal cavity or to the abnormal 

position. 
Borborygmi characteristic. 

HYDROTHORAX. 

Definition : a serous transudate (non-inflammatory) into 
the pleural cavity. It is usually a part of general 
dropsy, but may occur with but slight oedema of the 
lower extremities. 

In renal disease and anaemia it is usually bilateral. 
In heart disease it is commonly unilateral, but if 

bilateral is apt to be unequal on the two sides. 
In venous obstruction it may be either unilateral or 

bilateral. 
Signs. 

INSPECTION frequently reveals 

CYANOSIS, profuse perspiration. 

EXPRESSION of anxiety. 

DYSPNCEA, orthopnoea, even without exertion ; respir- 
atory movements limited. 

ABSENCE OF INFLAMMATORY SIGNS. 
PALPATION reveals 

NO TENDERNESS or rise of temperature. 
PERCUSSION and AUSCULTATION demonstrate 

signs of unilateral or bilateral effusion, similar to 

those in pleurisy, without the presence anywhere of 

friction sounds or other evidences of inflammation. 

HEMOTHORAX. 

Definition : an effusion of blood into the pleural cavity 
as distinguished from hemorrhagic pleurisy. 

Signs largely those of hydrothorax, with evidence in the 
pallor and effect on the circulation of considerable loss 
of blood. 



SIGNS IN THE DISEASES OE THE PERICARDIUM 153 



DISEASES OF THE PERICARDIUM, HEART, 
AND GREAT VESSELS. 

RARE AFFECTIONS OF THE PERICARDIUM, essen- 
tially undemonstrable during life, even with the help of 
history and symptomatology. These include 

Absence or Defects of the Pericardium. 

Tumors, Hydatids, and Syphilis of the pericardium. 

PERICARDITIS. 

Definition : inflammation of the pericardium. 
Signs. 

INSPECTION. 

EXPRESSION of anxiety common ; expression of pain 
upon change of posture or deep pressure over the 
heart. 

POSTURE, usually in dorsal semi-recumbency. 

VENOUS distention (ectasia) in the neck in rare cases 
where effusion makes pressure upon the superior 
vena cava. 

PRECORDIAL REGION prominent. 

In Children, owing to the pliancy of the chest- 
wall. 
In Adults, rare, though it may be present with 
effusion of 12 to 15 ounces. Potain saw it with 
much less. 

INTERCOSTAL DEPRESSIONS, may be obliterated, 
or bulging of intercostal spaces may be present 
over a large pericardiac effusion (paresis of the in- 
tercostal muscles). 

BULGING OF EPIGASTRIUM occasionally present 
with a large effusion, though it does not occur 
early, owing to the ready displacement of the lungs 
before much lowering of the diaphragm is effected. 

STUPOR, DELIRIUM, CONVULSIONS, and COMA 



154 



PHYSICAL DIAGNOSIS OF THE CHEST. 



may occur in the late stage, with cardiac failure 
and venous stagnation. 
DYSPNCEA is usually present both early and late. 
APEX BEAT. 

Forcible and rapid, and increased in area in the 

first stage. 
Weak or absent in recumbency, but may, in the 
presence of effusion, become both visible and pal- 
pable in forward inclination of the body, as in the 
knee-elbow posture. Weakness of the apex beat 
may also be due to simple weakening of the car- 
diac muscle, usually late. 
JPALFATION. 

PULSE not necessarily affected, except in rate, even 
when the heart is under considerable pressure from 
effusion. 
APEX BEAT elevated apparently, and changed with 

posture. 
FRICTION FREMITUS common in the early stage. 
PERCUSSION. 

IN THE FIRST STAGE negative. 
IN THE SECOND STAGE, 

Dulness corresponds largely to the amount of 
effusion. 
Early, it is usually first to be detected at the 
base of the heart in the second interspace, and 
to the right of the sternum in the fifth inter- 
space (this is a very important sign). A quan- 
tity of fluid less than four ounces may not be 
recognizable. 
Later, dulness extends to the left of the apex beat. 
In large effusions flatness and dulness occur 
in a triangular area, with its apex extending 
above the base of the heart, the base below, 
and extending far to the right of the sternum 
and to the left of the mammillarv line. 



SIGXS IN THE DISEASES OF THE PERICARDIUM. 155 

Dulness in recumbency becomes much in- 
creased in area in the upright posture, and 
may cause bulging of intercostal spaces 
which before were sunken. 
A ZSCLL TA TIOX. 
FRICTION SOUNDS. 

Time synchronous with cardiac movements "too 
and fro/' systolic and diastolic. They may at 
times disappear for a few beats and return. 
They occur independent of respiration, but 
may be somewhat influenced by respiration. 
They may be present for the first few hours, 
or may last during the greater part of the 
disease, and reappear after resorption of the 
effusion. 
Seat, over the precordia, usually first heard over 
the base, but may be loudest at the apex or over 
the right ventricle. 
Character. 

Quality, grazing, rough, harsh, or soft, and at 

times squeaking. 
Intensity variable, may be heard at a distance 
from the chest, may be increased by pressure 
of the stethoscope or by exercise, and may be 
influenced by respiration. 
Duration : they disappear with the occurrence 

of effusion or adhesion. 
Propagation : they are feebly transmitted, and 
are usually confined to the precordia. 
HEART SOUNDS. 

Early, normal but rapid. 

Letter, weakened, with the occurrence of a large 
effusion, which at first muffles them and later 
weakens them by weakening the heart muscle. 
Arrhythmia may occur with weakening of the 
heart muscle by pressure or adhesion-. 



156 PHYSICAL DIAGNOSIS OF THE CHEST. 

RESPIRATORY SOUNDS. 

Bronchial breathing may be developed over lung 
adjacent to and compressed by the effusion. It 
may disappear with change of posture to reap- 
pear over other parts. 

MEDIASTINO-PERICARDITIS. 

Definition : inflammation leading to adhesion between 
the parietal layer of the pericardium at the base and 
the wall of the chest or mediastinal tissue. In such 
cases the two layers of the pericardium are apt to be ad- 
herent. Fibrous bands or adhesions may implicate the 
great vessels at the base, and also the pleura and 
diaphragm. 
Signs. 

INSPECTION may show— 

INTERCOSTAL SPACES retracted with each systole. 
DYSPNCEA, ARRHYTHMIA, and weakening of the 
apex beat, and other signs of pericarditis may be 
present. 
INSPIRATORY SWELLING OF THE JUGULARS has 
been noticed, probably from compression of the 
innominate vein or superior vena cava. 
PALPATION. 

PULSUS PARADOXUS has been noticed in some cases 
(see page 54). Pulse may be irregular. 
PERCUSSION. 

AREA OF CARDIAC FLATNESS may be increased, 
v since adhesion of the pericardium to the chest-wall 
prevents expansion of the lung in front of the heart. 
AREA OF CARDIAC DULNESS may be increased as 
an indication of cardiac enlargement following de- 
generation. 
A TJSCUL TA TION. 

MURMURS, systolic aortic, or pulmonic, most marked 
on inspiration, may be heard in some cases. 



SIGNS IN THE DISEASES OF THE PERICARDIUM. 157 

HYDRO-PERICARDIUM. 

Definition : Serous transudate (non-inflammatory) into 

the pericardium, usually as a part of a general dropsy. 
Signs similar to those of pericarditis with effusion, minus 

the features dependent upon inflammation and pyrexia. 

H>£MO-PERICARDIUM. 

Definition : effusion of blood into the pericardium, 

usually sudden onset, with local 
Signs similar to those of hydro-pericardium. 

PYO-PERICARDIUM. 

Definition \ purulent effusion into the pericardium. 
Signs, those of inflammatory effusion. 

PNEUMOPERICARDIUM. 

Definition : gas in the pericardium. Usually it is ac- 
companied by fluid (pneumo-pyo-pericardium). Onset 
usually sudden. 
Signs. 

INSPECTION. 

EXPRESSION anxious or pained. 
CYANOSIS, sudden collapse. This may be due to 
pressure upon the great vessels at the base of the 
heart. 
PRECORDIAL PROTRUSION of the chest-wall and 

bulging of the intercostal spaces. 
DYSPNCEA. 
PALPATION. 

PULSE rapid, weak, small, and may be irregular. 
APEX BEAT absent, or may become visible and pal- 
pable upon forward inclination of the body. 
PMMCUSSION. 

TYMPANITIC RESONANCE over the air in the upper 

part of the cavity. 
FLATNESS over the fluid. The relative position of 
these changes with the change of posture. 



158 PHYSICAL DIAGNOSIS OF THE CHEST. 

AUSCUL TA TIOJST. 

FRICTION SOUNDS, metallic in quality, sometimes 
audible. 

METALLIC TINKLING, or gurgling, splashing, churn- 
ing sounds, metallic in quality, sometimes heard, 
even by the patient or others. 

HEART SOUNDS, metallic in timbre. 

CONGENITAL ANOMALIES OF THE HEART AND 
GREAT VESSELS. 

Definition : the heart may be 
TOO SMALL or 

TOO LARGE, or may occupy various 
ABNORMAL POSITIONS. 
ITS CA VITIJES may be too small or too large, or may 

be crossed by abnormal bands ; also 
THE SEPTA between them may be deficient, or foetal 

openings may remain patulous. 
THE AORTA and PULMONARY ARTERY may 
be abnormally small. 
Signs : many of these abnormalities have existed during 
a part or the whole life without discoverable symptoms 
and signs. Usually they show at some time physical 
evidences, of which the following are the chief: 
INSPECTION. 

CYANOSIS, early in occurrence, is the most marked 
sign of congenital cardiac deformity, though its 
presence is not diagnostic, and its absence does not 
always exclude a defect. It is not infrequently 
entirely absent, slight in amount, or late in de- 
velopment. Some cases of congenital cyanosis 
may be due to abnormality of the pulmonary 
capillaries. 
FAULTY DEVELOPMENT OF THE BODY is a natural 

effect of a defective heart. 
PRECORDIAL PROTRUSION is common. 



SIGNS IN THE DISEASES OF THE HEART. 159 

ABNORMAL CARDIAC ACTION, arrhythmia and the 

signs of cardiac enlargement. 
DYSPNCEA. 
PALPATION. 

PRECORDIAL THRILL not uncommon. 
A USCULTA TION. 

MURMURS may indicate 

Patulous Ductus Arteriosus. 

Seat. 

Posteriorly in the left interscapular region 
at the level of the third and fourth dorsal 
vertebrae. 
Time, systolic. 
Character. 
Intensity. 

Increased on inspiration. 
Diminished on expiration. 
Uniform on holding the breath. 
Patulous Foramen Ovale (according to Sansom). 
Seat. 

Anteriorly at the level of the third and 
fourth costal cartilages, to the left of the 
sternum. 
Time, systolic and presystolic murmurs present. 
Perforation of the Inter-ventricular Septum 
(according to Roger). 
Seat. 

Upper third of the precordial space about the 
third interspace. 
Character. 

Limited area, not propagated, unaffected by 
respiration or posture. 

CARDIAC ATROPHY. 

Definition : a degenerative loss of muscular volume, gen- 
erally as a result of arterio-sclerosis, which, however, 



160 PHYSICAL DIAGNOSIS OF THE CHEST. 

usually causes cardiac enlargement, exceptionally atrophy. 
It accompanies general marasmus from disease or age, 
and results in diminution in the actual size of the heart, 
unless dilatation occurs. 
Signs. 

INSPECTION. 

GENERAL signs of marasmus and poor blood-supply. 
LOCAL. 

Apex Beat faint or absent, even under emotional 
excitement, which tends to render it more visible 
and palpable. 
PALPATION. 

APEX BEAT and PULSE weak. 
PERCUSSION. 

CARDIAC DULNESS diminished in both deep and 
superficial areas. Allowance must be made for the 
lung in all cases. 
An Enlarged Heart overlapped by lung may show 

but little dulness. 
Marked Emphysema may obliterate all dulness 
of the heart whether of normal size or en- 
larged. 
detraction of the Lung with displacement of the 
heart may increase relative flatness and dul- 
ness. 
A USCULTA TION. 

HEART SOUNDS will depend upon the strength of 
the heart muscle. 
First Sound, especially weak or absent at the apex. 
Second Sound, pulmonic distinct, aortic apt to be 
weak. 

CARDIAC HYPERTROPHY. 

Definition : muscular thickening of the walls of one or 
more cavities of the heart. It rarely occurs without 
some degree of enlargement (dilatation of the cavities). 



SIGNS IN THE DISEASES OF THE HEART. 161 

Signs. 

INSPECTION. 

PROMINENCE OF THE PRECORDIA in children. 
APEX BEAT. 
Force increased. 
Area increased ; sometimes movement of the whole 

precordia. It extends to the left of normal. 
Epigastric Pulsation strong in hypertrophy of the 
right ventricle. 
CAROTIDS beat forcibly. 
PALPATION confirms inspection. 
PULSE regular, full, and forcible. 
PERCUSSION. 

CARDIAC DULNESS increased to the right of the 
sternum in hypertrophy of the right ventricle, and 
markedly to the left of normal if the left or both 
ventricles are enlarged. 
CARDIAC FLATNESS increased in area from dis- 
placement of the lung. 
A USCULTA TION. 

In the absence of valvular lesions the heart sounds 
are apt to be sharp, loud, and often peculiarly 
ringing. 

HYPERTROPHY WITH DILATATION gives more pro- 
nounced evidences of enlargement, but the signs otherwise 
are similar as long as hypertrophy compensates. 

CARDIAC DILATATION. 

Definition : abnormal increase in the size of one or more 
of the cavities of the heart, whether the walls are atten- 
uated or normal. 
Signs. 

INSPECTION reveals— 

EVIDENCES OF POOR CIRCULATION. 
11 



162 PHYSICAL DIAGNOSIS OF THE CHEST. 

JUGULAR VEIN varicosed, and pulsating with marked 

dilatation of the right heart. 
APEX BEAT absent or very weak and undulatory in 
character, with no definite point of maximum in- 
tensity. 
FALPATION. 

PULSE and APEX BEAT weak and rapid and fre- 
quently irregular. 
PERCUSSION shows— 

DULNESS and flatness increased. 
A VSC UL TA TI O V. 

HEART SOUNDS soft, feeble, apt to be abrupt, and 
frequently of equal length. 
Second Sot(H(( may be inaudible at the apex and the 
First Sound reduplicated. 
Arrhythmia frequently present. 
MURMURS if present are apt to be of slight intensity. 

MYOCARDITIS. 

Definition : diffuse or circumscribed inflammation of the 
wall of the heart. 

Acute, ending in suppuration, resolution, or fibrosis. 

Chronic, commonly considered as including various 
degenerations which are prone to accompany and fol- 
low inflammation. It may result from atheroma, cal- 
cification, thrombosis, or embolism of the coronary 
artery, with resulting infarction*, which may be 
hemorrhagic, anaemic, or infected. The chronic form 
is apt to accompany pericarditis or endocarditis. The 
effect in some cases depends upon direct local work 
of micro-organisms, in others upon toxins or toxal- 
bumins. 
Signs, 

SIGNS OF ACUTE MYOCARDITIS: this form is 
present typically in typhoid fever, and also may be 
present in diphtheria, scarlet fever, cerebro-spinal 



SIGNS IN THE DISEASES OF THE HEART. 163 

meningitis, variola, erysipelas, and in acute endo- 
carditis and pericarditis. 

In addition to the signs of these diseases a few or 
many of the following may be present : 
INSPECTION. 
Pallor. 

Dyspnoea and Sighing Respiration. 
Apex Beat absent. 
PALPATION. 

Coldness of the extremities. 

Pulse feeble, often extremely irregular (arrhythmia). 
PERCUSSION. 

Cardiac Dulness normal unless dilatation or peri- 
cardial effusion is present. 
AUSCULTATION. 
Arrhythmia. 
Tachycardia. 

Heart Sounds muffled. They are apt to assume 
the foetal type. 
SIGNS OF CHRONIC MYOCARDITIS. 
INSPECTION and PERCUSSION. 

The signs of weak heart as in the acute form ; also 
Cyanosis and (Edema of the Extremities. *The 
signs of acute febrile disease absent. 
PALPATION. 
JPulse shows — 

Marked Arrhythmia present early and frequently 

persistent, but little influenced by drugs. 
Irritability of the Heart upon slight excitement 
or exertion. 
AUSCULTATION. 

Heart Sounds muffled, indistinct, irregular. 
First Sound reduplicated not infrequently. 

CARDIAC LIPOMATOSIS, or fatty infiltration of the 
heart. 



164 PHYSICAL DIAGNOSIS OF THE CHEST. 

Definition : an accumulation of fat upon the heart. This 

is usually a part of general obesity, although it may 

occur occasionally in lean persons. 

In modeeate amount it has little or no effect upon 
the heart's function, though the amount consistent 
with health varies with age, habits, constitution, etc. 

When excessive, and deposits take place not only on 
the surface, but infiltration occurs between the muscle 
fibres, the result is hampering of the heart's action, 
and finally pressure-atrophy with true fatty degenera- 
tion, to which the resulting symptoms and signs are due. 

CARDIAC FATTY DEGENERATION. 

Definition : a more or less localized or disseminated retro- 
gressive change of the muscular fibres of the heart into 
fat, almost without exception associated with hyaline 
and fibroid degeneration. 
Signs : these become evident only when degeneration has 
become sufficient to cause dilatation from weakening of 
the muscular wall. 
INSPECTION may reveal 

ARCUS SENILIS and other signs of age. 
• VENOUS STASIS and evidence of insufficient blood- 
supply to the organs. 
CEDE MA of the extremities is present in the late 

stage. 
DYSPNOEA may be pronounced on slight exertion. 
PALPATION. 

PULSE feeble, especially when the arm is held high. 
It is frequently irregular in both time and force, 
and may be slow. In a late stage it is always 
rapid. 
PERCUSSION. 

CARDIAC DULNESS, superficial and deep, increased. 
A USCULTA TION. 

HEART SOUNDS weak, and are apt to be modified 



SIGNS IX THE DISEASES OF THE HEART. 165 

and obscured by relative murmurs (dependent upon 
dilatation). 
ARRHYTHMIA and, late, delirium cordis. 

RUPTURE OF THE HEART, traumatic or non-traumatic. 
Non-traumatic or spontaneous rupture of the heart occurs 
suddenly in case of degenerative changes, the weakened 
heart-wall being subjected to some sudden strain whether 
from mental or physical cause. It may occur in such a 
heart during perfect tranquillity of mind and body. 
The Signs obtainable are but few, owing to the sudden- 
ness of the accident. The person may, with or without 
an outcry, fall at once into collapse, or, as occurs not 
infrequently, live several hours, manifesting 
CYANOSIS, COLD SWEATS, DYSPNOEA, with, 
perhaps, convulsions and coma. In other cases, where 
the rupture is at first small, there may be attacks of 
nausea, vomiting, anxiety, vertigo, syncope, with or 
without evidence of anginal pain. 

SYPHILIS OF THE HEART may show no signs, and 
when present they do not differ from those of myo- 
carditis and degeneration from other causes. 

ANEURYSM OF THE HEART. 

Definition : though cardiac dilatation is in so far a species 
of aneurvsm, the term is limited to localized attenuation 
of the wall, acute or chronic, with circumscribed dilata- 
tion which may be distinctly saccular. 

Signs : usually neither the subjective nor objective features 
are distinctive, and the disease may be latent, revealed 
only by autopsy after sudden death, otherwise the signs 
are apt to be those of myocarditis. More or less 
CYANOSIS, 
DYSPNCEA, 
ARBHYTHMIA, 



166 PHYSICAL DIAGNOSIS OF THE CHEST. 

TACHYCARDIA and other signs of weak heart. Ex- 
ceptionally there is evidence of pulsating tumor and 
increase of cardiac dulness. 

DIASTOLIC MURMURS have been heard, probably 
due to the regurgitation of blood from the aneurysmal 
sac. 

THROMBOSIS OF THE HEART (ante-mortem). 

Definition : formation of a clot within the cavities of the 
heart. This is usually adherent to its walls, and some- 
what firmly enmeshed among its tendinous and mus- 
cular bands, but it may form polypoid structures <>r non- 
adherent floating masses. 
Two factors usually combine to it- occurrence: 

A retarded circulation. 

A toxic condition of the blood or local diseased foci 

upon the wall of the heart. 

Signs: the process may not he apparent during life. 

When the coagula interfere with the valves, or detached 

masses form emboli, the symptoms and signs may vary 

widely. The diagnosis is usually impossible. 

TUMORS OF THE HEART. 

Carcinoma usually secondary, by extension from neigh- 
boring structures. 
Sarcoma more rare. 
Myomata and Fibromata occasional. 
SIGNS very uncertain. 

PARASITES, such as CYSTICERCUS and EcHINOOOCCUS, 

are relatively rare, and their diagnosis usually impossible, 
except from their recognition in other organs and the 
presence of cardiac disturbance of more or less gravity. 

NEUROSES OF THE HEART. The so-called cardiac 
neuroses do not properly claim notice here. 



SIGNS IN THE DISEASES OF THE HEART. 167 

Angina pectoris and Palpitation are subjective. 
Bradycardia and Tachycardia and Arrhythmia 
are considered under the pulse. 

ACUTE ENDOCARDITIS. 

Definition : inflammation of the endocardium largely con- 
fined to the valves. It may be 

Simple, characterized by the growth upon the valves 
of vegetations of granulation tissue, capped with 
fibrin and accompanied by subendothelial, small- 
celled infiltration. The tendency of this is to 
resolution by absorption of the vegetation with 
nodular thickening and contraction. 
Malignant or ulcerative endocarditis is marked by 
connective tissue vegetative proliferation, accom- 
panied by necrosis with ulceration or suppuration. 
In either case the vegetations may be carried away 
as emboli, to form corresponding simple or infective 
infarcts. 
Signs. 

SIGN OF SIMPLE ENDOCARDITIS : these, apart 
from the symptoms and history, are not characteristic. 
Many cases are latent, with but little or no evidence 
of cardiac trouble. When the disease is confined to 
the wall of the heart (not involving the valves) signs 
are usually absent. 
In addition to the evidences of the primary disease 
INSPECTION may reveal — 
Facial anxiety. 

Apex Beat is apt to be increased in force and area 
in the beginning. 
PALPATION elicits — 

False full, bounding, and perhaps irregular. 
PERCUSSION negative in uncomplicated cases. 
AUSCULTATION may be negative, even with marked 
lesions ; but a soft 



168 PHYSICAL DIAGNOSIS OF THE CHEST. 

Systolic Mtw»nn\ usually at the apex, is oOfflmoo. 
H< duplication of the Second Sound may be 
present. 
SIGNS IX ULCERATIVE ENDOCARDITIS. 

NOT DISTINCT apart from the septic or typhoid 
manifestations which are usually present as a part 
of the causative affection. In such eases the pres- 
ence of endocardia] murmurs with other signs of 
valvular disease, and the evidences of embolic 
processes) point strongly to the diseases in question. 

CHRONIC ENDOCARDITIS. 

Definition : it is essentially a sclerosis of the valves which 
produces deformity with more or less consequent ob- 
struction or incompetence. 

Signs: when the disease is eonfined to the wall of the 
heart (rare) it may show no signs. Even valvular 
disease may not he recognizable by signs during life. 

INSPECTION may disclose more or less of the fol- 
lowing : 

ANXIETY. 

CYANOSIS of the prolabia and of the nose, chin, 
cheeks, and tips of the ears is common in mitral 
regurgitation ; marked when incompetence occurs. 

PALLOR of the face, especially in aortic and mitral 
obstruction. 

ICTERUS common, and may he extreme, in case of 
secondary duodenal catarrh. 

CEDEMA of the extremities, progressing upward in 
case of cardiac weakness. 

PRECORDIAL PROMINENCE sometimes present in 
children with cardiac enlargement. 

APEX BEAT. 

Position : displaced to the left and downward. 
Strength : freak and invisible in dilatation ; im- 
moderately strong in hypertrophy. 



SIGNS IN THE DISEASES OF THE HEART. 169 

CAROTIDS show excessive beating in hypertrophy 
and in aortic regurgitation. 

JUGULAR PULSE is present in marked tricuspid re- 
gurgitation. 

DYSPNCEA on exertion amounting to orthopnoea in 
advanced cases. 
PALPATION. 

APEX BEAT displaced with enlargement of the ven- 
tricles. 

PULSE. 

Compressible, weak and small in cardiac incom- 
petence and frequently irregular. 
Full, bounding, powerful in hypertrophy. 
Diastolic Collapsing, in aortic regurgitation. 
Small, flirt/ in aortic obstruction. 

FREMITUS, or thrills, correspond to the seat of the 
murmur. Most frequent in mitral obstruction, pre- 
systolic, at the apex ; less frequently in aortic ob- 
struction, at the base ; rarely with regurgitant mur- 
murs ; common over the subclavians and carotids (sys- 
tolic) in aortic regurgitation. (See Fremitus, p. 59.) 
PERCUSSION. 

OUTLI IM E OF TH E H EART is extended to the left and 
right in enlargement of the organ, according to the 
cavities affected. Often it is difficult, sometimes 
impossible, to make out by percussion the actual 
size. Evidence of enlargement is an important 
sign in differentiating from functional murmurs. 
A USC UL TA TION. 

THE HEART SOUNDS may be 
Replaced by murmurs, 

Modified in character, muffled, accentuated, or 
Reduplicated, or otherwise more or less 
Changed in Rhythm. 

MURMURS usually accompany lesions. (See the 
various Valvular Lesions,.) 



170 PHYSICAL DIAGNOSIS OF THE CHEST. 

Quality. 

Obstructive murmurs usually harsh and high- 
pitched. 

Regurgitant murmurs apt to be blowing and 
soft. Either of them may be musical or 
soft, like whispered "who/' <>r creaking or 
grating. 
Intensity and Duration* 

Sometimes Very Faint even with serious lesion-. 
All murmurs arc apt to become weak with 
weak heart action, grave lesions being in such 
cases not infre(juentlv unaccompanied l>y mur- 
murs. Sometimes indistinct murmurs become 
loud or of changed quality and pitch after ex- 
ercise or the administration of cardiac tonics. 
In tumultuous action of the heart, especially 
with arrhvthmia, all Bounds may be confused. 
and murmurs only become audible after car- 
diac stimulation. 

Sometimes Murmurs are so Loud as to be 
heard at a distance from the patient. 

Certain Postures may intensify or bring out a 
murmur. Asoulay recommends dorsal pos- 
ture, head Hexed, chin in contact with the 
chest, arms elevated, thighs and legs Hexed on 
the abdomen. Sitting or STANDING posture 
may intensify murmurs. 

According to Gerhardt, in beginning aortic insufficiency 
a murmur which may be absent in recumbency may be 

heard in the upright posture, while the reverse is true in 
beginning mitral insufficiency. 

Pitch varies with the lesion, and the tension and 
rapidity of circulation. It is of value in 
differentiating between two murmurs occur- 
ring at the same time. 

Time refers to the relation in the cardiac cycle. 



SIGNS IN THE DISEASES OF THE HEART. 171 

Systolic refers to the contraction of the ventri- 
cles (the auricles being ignored), and hence con- 
comitant with or destroying the first sound, 
and with the apex beat and carotid pulse. 
Indirect or Regurgitant. 

Mitral and Tricuspid. 
Direct or Obstructive. 
Aortic and Pulmonic. 
Diastolic refers to the dilatation of the ventri- 
cle, hence not with first sound, apex beat, and 
carotid pulse. 
Direct, Obstructive. 

Mitral and Tricuspid, occurring in the latter 
part of diastole just before systole (hence 
presystolic). 
Indirect or Regurgitant. 

Aortic and Pulmonic, occurring in the first 
part of diastole, taking the place of the re- 
spective aortic and pulmonic second sound. 
Transmission or Diffusion. 

Extent : the murmur of aortic regurgitation may 
be heard very widely from its seat, even as 
low as the femoral vessels, though rarely. A 
murmur may be very limited in diffusion, as 
in mitral obstruction (heard only about the 
apex). A murmur must necessarily be loud 
to be well transmitted. 
Medium of transmission. 
The Vessels. 

TJie Aorta and its branches transmit the mur- 
murs of both aortic obstruction and re- 
gurgitation, which are therefore frequently 
heard above the base of the heart and 
posteriorly along the left side of the ver- 
tebral column, especially above the fifth 
dorsal vertebra. 



172 PHYSICAL DIAGNOSIS OF THE CHEST. 

The Pulmonary Artery carries the pulmonic 

obstructive murmur up under the second 
left interspace, hence it is not widely dif- 
fused. 
The Sternum and Ribs. 

Loud Aortic Muramrs are frequently trans- 
mitted down the sternum owing to the 
comparative proximity of the vessel to 
the hone over it. 
Mitral Systolic Mwrmwrs axe transmitted to 
the left along the ribs from the apex, 
which strikes the chest-wall at the time 
they are produced. 
The Diaphragm doubtless transmits the mur- 
mur of aortic regurgitation. The murmur 

is produced during diastole while the left 
ventricle is in most intimate contact with 
the diaphragm, the blood being directed 
downward toward it. The murmur is there- 
lore transmitted along the diaphragm to its 
attachment at the end of the sternum, and 
along the costal arch close to the left of the 
sternum. Here it is frequently heard with 
greatest intensity. 

The Blood Current within the heart. In 
general, murmurs are transmitted best in 

the direction in which the blood is flowing 

at the time the murmur occurs. 

In Mitral Obstruction the murmur is carried 
into the ventricle toward the apex with 
the blood-current. It is not usually trans- 
mitted to the left, because the apex is not 
in contact with the chest-wall at the time. 

In Mitral Regurgitation the murmur is un- 
doubtedly carried into the auricles with 
the blood, as may be verified in some 



SIGNS IN THE DISEASES OF THE HEART. 173 
cases where this lesion is complicated by 

CONSOLIDATION OF THE LUNG at the 

base of the heart, which transmits the 
murmur to the surface at that point, or 
where there is retraction of the lung un- 
covering the auricle anteriorly. The 
normal lung, owing to the oblique posi- 
tion of the heart, is relatively thick over 
the base, and does not transmit the mur- 
mur. 
Seat of a murmur : the place of its greatest intensity. 
Valvular Lesions. 

AORTIC INSUFFICIENCY. 

DEFINITION : a defect of the aortic valve, allow- 
ing regurgitation into the left ventricle during 
diastole. 
SIGNS. 

Inspection. 

Pace usually pale. 

Precordial Reg-ion is apt to be prominent in 

children, in cases of long standing. 
Apex Beat. 

Area enlarged, reaching to the left, it may be 

even to the mid-axillary line. 
Force of impact, increased where compensa- 
tion is good, sometimes shaking the chest 
markedly or agitating the entire trunk. 
Systolic Retraction of an intercostal space 
over the apex, occasionally present. It may 
be due to retraction of the lung and action 
of the heart in svstole. 
Carotids and other arteries pulsate violently and 

distinctly collapse in diastole. 
Capillary Pulse (Quincke) may be seen in a line 
of artificial hyperemia drawn upon the sur- 
face, and in the bed of the finger-nails, fundus 



174 PHYSICAL DIAGNOSIS OF THE CHEST. 

of the eye, and in the mucous membrane when 
slightly pressed beneath a glass slide. 

Rhythmical Swelling- of the Uvula (Midler) 
may sometimes be seen. 

Faint Venous pulse lias been seen in the hand 
and arm (Quincke) — rare. 
Palpation reveals also 

Apex Beat displaced, area enlarged, and force 
usually increased. 

Fremitus. 

Diastolic Thrill is rarely felt over the base 

of the bear! in the aortic area. 
Systolic Thrill commonly felt over the 
carotids and subclavian arteries. 

Pulse: u water hammer," - pistol," u collapsing n 
in diastole. When the wall of the left ven- 
tricle is strong the pulse is lull, bounding, and 

sudden in systole, hut falls away from the 
finger, leaving an apparently empty artery, in 
diastole. This is especially marked when the 
arm is held high, owing to the effecl of gravity 

on the fall of blood directly toward the ven- 
tricle. Examine the arm in both the high 
and low positions and note the different 
Percussion, 

Cardiac Dulness over an increased area, de- 
fining the border of the heart far to the left 
of the nipple line. 

Cardiac Flatness much increased in area from 
enlargement of the heart and crowding hack 
of the lung (see p. 160). 

Dulness maybe marked in the left second inter- 
space in case of relative aortic insufficiency 
from dilatation of the aorta at its beginning. 
Aus( ulUttion. 

Murmur. 



SIGNS IN THE DISEASES OF THE HEART 175 

Time : diastolic, with or obscuring the second 

sound. 
Seat : in the aortic area, second right inter- 
space, sometimes over the sternum at this 
level, occasionally over the lower end of the 
sternum and costal arch close to the left, 
over the attachment of the diaphragm. In 
the latter case, I believe the murmur is 
transmitted along the diaphragm (see p. 172).. 
Character, 

Quality usually somewhat soft, gushing, or 
swishing. Occasionally rough where de- 
posits have occurred upon the valves. It 
may be musical, and especially is it apt 
to be so in relative insufficiency (Groedel). 
Intensity and pitch variable. It is usually 
loudest with large openings ; sometimes 
loudest with the arms elevated. Cases 
have been reported where the murmur 
was intermittent. 
Duration long. 
Propagation. 

Down the Sternum, owing to the proximity 

of the aorta to this bone over it. 
Toward the Apex, down the left ventricle. 
Along the Diaphragm to the lower part of 
the sternum and the costal arch close to 
the left. 
Above the Base of the heart, along the ves- 
sels. When the murmur is loud it may 
be very widely disseminated, even to the 
main arteries of the extremities (rare). 
Associated Murmurs. 

Aortic Systolic murmur may often be heard, 
though insufficiency more frequently ex- 
ists alone than stenosis. 



176 PHYSICAL DIAGNOSIS OF THE CHEST. 

Mitral Systolic murmur frequent on account 
of relative mitral insufficiency from di- 
latation of the left ventricle. The 
murmur of aortic insufficiency may be 
absent where there is a marked insuffi- 
ciency of the mitral valve (Timofejew 
and Bolkin). 

Presystolic Murmur sometimes beard at the 
base, and may he accompanied by a frem- 
itus. 

The caii.se is uncertain, hut probably it is due to 
vibration by the current from the auricle of the 
larger segment of the mitral valve, previously 

floated out hv the refluent blood from the aorta. 
Systolic Murmurs are usually heard over the 

carotids and subclavians accompanied by 
a fremitus, both probably due to the sud- 
den systolic filling of these vessels, which 
were previously emptied in diastole. Both 
murmur and thrill over a subclavian may 
disappear when the arm is raised above 
the head. 
Double Murmurs (systolic and diastolic) are 
sometimes heard over the larger arteries, 
such as the femoral. 

Heaet Sounds. 

Mitral and Tricuspid first sounds intact if 
the corresponding valves are competent. 

Aortic Second sound destroyed. 

Pulmonic Second sound normal or obscured 
by the loud aortic murmur. It is only ac- 
centuated with disturbed compensation, re- 
sulting in relative mitral insufficiency and 
pulmonary engorgement. This accentua- 
tion disappears with failing compensation 
of the right ventricle. 



SIGNS IN THE DISEASES OF THE HEART. 177 

AORTIC OBSTRUCTION. 

DEFINITION : a defect of the aortic valve interfering 
with the current from the left ventricle into the 
aorta. 
SIGNS. 

Inspection,* 

Face is apt to be pale. 

Precordial Region may be prominent where car- 
diac enlargement occurs in childhood. 
Apex Beat displaced downward, sometimes to 
the sixth interspace and somewhat to the 
left. 
Area and force variable. 

Carotids and other arteries show but little pul- 
sation. 
Palpation. 

Apex Beat, when hypertrophy is good, is marked 

as contrasted with the small pulse. 
Fremitus, systolic thrill sometimes felt in the 
aortic area in pure aortic stenosis, which is 
rare. 
Pulse tardy, slow, small, and sometimes very 
hard and wiry. 
Percussion. 

Cardiac Dulness increased downward and to 
the left. 
Auscultation. 
Murmur. 

Time, systolic, with the first sound. 

Seat, aortic area. 

Character. 

Quality apt to be harsh, strident, sometimes 

whistling or hissing. 
Intensity and pitch vary in different cases. 
Duration long, owing to the relatively slow 
discharge of the ventricle. 
12 



178 PHYSICAL DIAGNOSIS OF THE CHEST. 

Propagation. 

Above the Base, into the carotids. 

Toward the Apex, and when loud 

Down the Sternum. 
Associated Murmurs. 

Aortic Diastolic murmur is usually present, 

as pure stenosis without regurgitation is rare. 

Heart Sounds. 

Mitral and Tricuspid sound- normal, the 
former often peculiarly loud, unless rela- 
tive mitral insufficiency exists as a result 
of dilatation of the ventricle. 
Aortic Second Bound feeble. 
Pulmonic Second) normal or accentuated. 
MITB AL 1 X 8 UFFIC1 E X( } . 

DEFINITION : a defect of the mitral valve allowing 

regurgitation into the left auricle during systole. 

SIGNS. 

Inspection reveals hut little abnormal, while com- 
pensation is efficient, except the signs of hyper- 
trophy in greater or less degree. When com- 
pensation fails, the visible signs are cyanosis, 
oedema, dyspnoea, cough, etc. 
Palpation during loss of compensation may reveal 
Pulse weak, small, rapid, and more or less irreg- 
ular. 
Apex Beat usually to the left, owing to enlarge- 
ment of the right heart and slight hypertrophy 
of the left ventricle. 
Percussion usually shows cardiac enlargement both 
to the right and left. Dulness may be found as 
high as the second rib, to the left of the sternum, 
owing to enlargement of the left auricle. 
Auscultation* 
Murmur. 

Time, systolic, destroying the mitral first sound. 



SIGNS IN THE DISEASES OF THE HEART 179 
Seat at the apex. 

Rarely it is heard with great, if not with equal inten- 
sity at the base, about two inches to the left of the sternum. 
This is thought (Naunyn) to be due to the propagation of 
the sound with the blood as it rushed into the point 
of the appendix of the left auricle, which in some cases, 
when enlarged, curves around and lies in front of the 
pulmonary artery. 

Character. 

Quality usually soft, blowing, like the whis- 
pered " who," occasionally rough, musical, 
hissing, or rasping, etc. 
Pitch and Intensity variable. 
Duration : it may last up to the second 
sound. 
Propagation commonly to the left of the 
apex, and when loud may be heard pos- 
teriorly at the lower angle of the scapula ; 
it is not usually heard at the base, and not 
above the base nor over the sternum. 
Heart Sounds. 

Second Pulmonic sound accentuated, owing 
to increased tension in the pulmonary artery, 
but the accentuation disappears when the 
compensatory hypertrophy of the right ven- 
tricle fails. 
MITRAL STENOSIS. 

DEFINITION : a defect of the mitral valve, inter- 
fering with the current from the left auricle into 
the ventricle. 
SIGNS. 

Inspection. 

Pallor of face and 

Cyanosis, more or less marked as compensation 

fails. 
Epigastric Pulsation from enlargement of the 
right heart. 



180 PHYSICAL DIAGNOSIS OF THE CHEST. 

Palpation. 

Fremitus, or thrill, presystolic, not infrequent at 
the apex. 

Pulse apt to be small and weak. When com- 
pensation fails it becomes rapid and extremely 
arrhythmic in both time and force. 
Percussion. 

Dulness often in the second interspace to the 
left of the sternum over the dilated auricle, 
and dulness also evident to the right of the 

sternum and to the left of the normal line 

when enlargement of the righl ventricle is 
marked. The left ventricle enlarges if at all 
by atrophy and dilatation from poor nutrition, 
but no hypertrophy occurs in it. 
Auscultation* 
Murmur. 

Time, presystolic, in the latter part of diastole, 
ending in the 6rst sound or in a systolic re- 
gurgitant murmur, which frequently is asso- 
ciated with it. 
Seat at the apex, sometimes just above and 
slightly to the left, because the left ven- 
tricle is displaced, backward to a degree and 
to the left, by the greatly enlarged right ven- 
tricle, which in this case gives the apex beat. 

Character. 

Quality^ rough, rumbling. 

Pitch, Duration, and Intensity variable. It 
is a relatively prolonged murmur. 
Propagation very limited. It is usually 

confined to a small area at the apex, and is 

not heard for to the right or left or at the 

base. 
Associated Murmurs. 

Mitral Systolic regurgitant murmur is 



SIGNS IN THE DISEASES OF THE HEART 181 

usually present, as obstruction rarely occurs 
without producing some incompetence of 
the valve. 

Pulmonic Diastolic murmur from relative 
insufficiency of the pulmonary valve, due to 
continuous high pressure in the pulmonary 
artery. This is heard only when the right 
ventricle is powerful, and may be absent 
when there is relative tricuspid insufficiency. 

Tricuspid Systolic murmur from relative 
insufficiency of that valve. When compen- 
sation of the right ventricle fails the heart 
becomes extremely rapid and irregular, and 
the sounds and murmurs faint, a condition 
termed delirium cordis. 
Heart Sounds. 

Mitral first sound, when not destroyed by an 
accompanying murmur of regurgitation, is 
intact and seemingly terminates the mur- 
mur. 

Tricuspid first sound is often peculiarly 
loud. 

Pulmonic second sound is accentuated in case 
the right ventricle is hypertrophied. Ac- 
centuation disappears with failing compen- 
sation of the right ventricle. 

Aortic second sound is apt to be faint. 

Reduplication of the second sound is fre- 
quent, probably from the difference in ten- 
sion in the pulmonary artery and aorta. 
FULMONABY INSUFFICIENCY. 

DEFI N ITION : a defect of the pulmonary valve allow- 
ing regurgitation into the right ventricle during 
diastole. It is usually congenital, but may be a 
part of a general endocarditis, or relative from 
dilatation of the pulmonary artery at its beginning. 



182 PHYSICAL DIAGNOSIS OF THE CHEST. 

SIGNS. 

Inspection* 

Apex Beat displaced to the left. 
Pulsation frequently visible in the 
Second Left Interspace Pulsation of the 
Right Ventbicle between the ensiform car- 
tilage and costft] arch. 
Palpation, 

Fremitus, diastolic thrill over the second left 

interspace, occasional. 
Pulse, generally regular but not large. May be 
variously affected, owing to the lesions of other 
valves usually present. 
Percussion, 
Dulness of the enlarged right ventricle to the 
right and left of the sternum. 
Auscultation, 
Murmur. 

Time diastolic, replacing the second pulmonic 

sound. 

Skat at the base in the second interspace. 

Character not peculiar, except that it is in- 
creased in intensity during expiration (Ger- 

hardt). 
PROPAGATION limited ; not transmitted into 
the cervical vessel-. Being usually loud, it 
may be heard over the whole heart, distinct 
over the right ventricle. 
Associated Murmurs. 

Tricuspid Systolic murmur from relative 
insufficiency is apt to occur. 

At a distance from the heart may occasionally be 

heard on inspiration an interrupted vesicular respira- 
tion, possibly due to pulmonary capillary pulse, anal- 
ogous to the collapsing capillary pulse of aortic re- 
gurgitation (Gerhardt). 



SIGNS IN THE DISEASES OF THE HEART. 183 

Heart Sounds. 

Mitral and Aortic sounds apt to be weak. 
Pulmonic Second destroyed by the murmur. 
Tricuspid accentuated/ if hypertrophy of the 
right ventricle be adequate and no relative 
insufficiency of the tricuspid valve occurs. 
PULMONARY STENOSIS. 

DEFINITION : a defect of the pulmonary valve in- 
terfering with the systolic current from the right 
ventricle. It is among the very rarest of acquired 
lesions, but most frequent of the congenital valve 
lesions, and usually associated with other anomalies. 
SIGNS. 

Inspection reveals deranged circulation and mal- 
formation and general arrest of development. 
Eyes prominent; Lips thick, red. 
Superficial Veins enlarged. 
Cyanosis often extreme. 
Thorax narrow and precordia prominent. 
Abdominal Protrusion. 

Finger Ends clubbed, blue ; nails curved, thick. 
Cardiac Impulse displaced and often increased 

so as to agitate the chest. 
Dyspnoea common. 
Palpation. 

Fremitus in the second left interspace. 
Apex Beat displaced. 
Pulse weak. 

Surface, and especially the extremities, cold. 
Percussion. 

Enlarged Right Ventricle, giving dulness to the 
right of the sternum. 
Auscultation. 
Murmur. 

Time, systolic, with the first sound. 
Seat, second left interspace. 



184 PHYSICAL DIAGNOSIS OF THE CHEST. 

TRICUSPID I SS I FFICIEXf F. 

DEFINITION : a defect of the tricuspid valve allow- 
ing regurgitation into the right auricle during Bys- 
tole. Except in foetal life, it is usually relative, 
consecutive to valve lesions which have caused 
dilatation of the right ventricle. 
SIGNS. 

Inspection, 
Face is apt to show more or less cyanosis. In 
marked insufficiency of long standing with fail- 
ure of compensation there is marked cyanosis 
with 
(Edema of the extremities. 
Ectasia of the superficial vessels. 
Prominence of the epigastric and right hypo- 
chondriac regions OCCUrs from enlargement of 

the liver. 
Dyspnoea. 
Pulsation of the right ventricle evident at the 

ensiform cartilage and epigastrium. 
Jugular Pulsation preseni in well-marked cases. 

The venae cava' and innominate vein have no valve, but 
for the production of jugular pulsation this vein must he 
sufficiently dilated to overcome the valve at its root, which 
otherwise long resists the backward pressure. 

Time, systolic. 

Seat, most marked on the right side. The bulb 
of the jugular first pulsates. Sometime- it 

may be seen just above the clavicle outside 
the sterno-cleido-mastoid. When the inter- 
nal jugular pulsates the external does al><>. 
Intensity : it only occurs with a relatively 

powerful right ventricle. 
Pressure easily obliterates all pulsation above 

the point of its application. 
77 is greatest during inspiration. 



SIGNS IN THE DISEASES OF THE HEART 185 

Hepatic Venous Pulsation is better felt than 

seen. 
Femoral Vein may pulsate if its valve (Eus- 
tachian) has been overcome by the dilatation 
of the vessel. 
Palpation. 

Apex Beat weak. 

Pulse weak, rapid, unless compensation is good. 
Hepatic Venous Pulsation may occur, since 
these veins have no valves. 
Time, systolic. 
Seat, chiefly in the left lobe, as it is most 

easily expanded. 
Intensity and character like that of an 
erectile tumor. 
Percussion. 

Cardiac Dulness increased, and may be obtained 

well to the right of the sternum. 
Hepatic Dulness increased. 
Auscultation. 
Murmur. 

Time, systolic, taking the place of the tricuspid 

first sound. 
Seat at the ensiform cartilage or the lower 

half of the sternum. 
Character. 

Quality usually soft, blowing. 
Intensity and pitch not peculiar. The mur- 
mur may be absent, and is often difficult 
to make out in the presence of several as- 
sociated murmurs. It is commonly over- 
looked. 
Propagation distinct to the 

Bight of the Sternum, sometimes even as far 

as the axillary line. 
Into the Jugular Vein, where the mur- 



186 PHYSICAL DIAGNOSIS OF THE CHI 

mur is loud and the venous pulse well 

marked. 
Associated Murmurs of the aortic and mitral 

valves are usually present. 
Heart Sounds. 

Mitral sound usually destroyed by inoom- 

» 

petence of the valve. 
Tricuspid sound absent. 
Aortic sound may be present, bul is weak. 
Pulmonic sound weak from the low ten-ion 
in the pulmonary artery. 
TRK l S VI /> 8 TENOS IS. 

DEFINITION : a defect of the tricuspid valve inter- 
fering with the presystolic current (auricular sys- 
tole) into the right ventricle. It is exceedingly 
rare, and is usually of fetal origin. 

signs: it is generally accompanied by other con- 
genital lesions which mask it. 
Inspection. 

The signs are those of extreme systemic venous 
stasis. 
Palpation, percussion, and auscultation signs not 

distinctive. So rare is this affection that the 
characteristics of the accompanying murmur, 
if present, are not definitely settled. Ilypo- 
thetically it has been described a- 

Time, presystolic. 

Seat, tricuspid area. 

Propagation limited to the right side of the heart. 

FUNCTIONAL ENDOCARDIAL MURMURS. 

These are due chiefly to anaemia and transient causes, 
such as fever, excitement, ete. 
Time, systolic; diastolic murmurs are usually organic. 
Seat, usually the base of the heart in the pulmonary area ; 

sometimes the aortic area ; occasionally at the apex. 



SIGNS IN THE DISEASES OF THE AORTA. 187 

Character, usually soft, blowing in quality. 
Propagation very limited. 
Associated Signs those of 

ANJEMIA, nervous excitement. 

HE All T normal in size, its sounds all present, though 
they may be slightly modified. 

ANEURYSM OF THE AORTA (THORACIC). 

Definition : a fusiform or saccular dilatation of the aorta 
in any part of its course, above the diaphragm. Its en- 
largement causes pressure, disturbing and destructive 
to neighboring organs. 

Signs. 

IJSTSPECTIOX may reveal 

AN INFLAMED AREA of reddened, thin, glazed skin 
covering the site of the aneurysm, if this has by 
pressure come sufficiently near the surface. 

LIVIDITY of the face, neck, and upper extremities 
from pressure upon venous trunks. Lividity and 
oedema, when sudden in occurrence, may be due to 
rupture into one of the great venous trunks. 

TURGESCENCE and VARICOSITY of the superficial 
veins points to deep-seated interference with venous 
trunks. 

EXPRESSION : the eyeballs may become prominent; 
expression of distress may indicate the more or less 
continuous boring pain commonly present. 

LOCALIZED CEDE MA results from pressure upon the 
superior vena cava or innominate vein. It may be 
absent from establishment of collateral circulation. 
Capillary turgescence may produce 

A THICK FLESHY COLLAR at the base of the neck, 
which may be unilateral. 

These pressure signs may of course be produced by other 
conditions, such as tumors, swellings, inflammatory contraction, 
thrombosis, etc. 



188 PHYSICAL DIAGNOSIS OF THE CHEST. 

inequality of the pupils, or persistent bilateral 
myosis, may result from pressure upon the sym- 
pathetic nerve trunks or branches. Pupil may be 
contracted on the affected side 

EMACIATION and ENFEEBLEMENT progressive. 

ENLARGEMENT or BULGING common at the rite 
of the aneurysm ; variable in size. 

Site. 

None Present when the Aneurysm is located 
at the Valves of Valsalva. The signs in 
this case are apt to be obscure. 

Bulging* to the Right of the Sternum in the 
second interspace, sometimes extending far into 
the infra-clavicular and mammary region, is 
apt to occiii' from aneurysm <>f the ascending 
portion, if large. More rarely it appears t<> 
the left of the sternum at a corresponding 
level. The sternum may be perforated. 

Bulging at the Upper Part of the Sternum 
and adjacent infra-clavicular region results 
from aneurysm of the transverse portion. 

Bulging Posteriorly, below the level of the 
fourth rib, to the left of the vertebral column, 
may result from aneurysm of the thoracic 
aorta. Very rarely it appears to the right of 
the vertebral column. Frequently there is an 
absence of a tumor. 
PULSATION, if visible, at the site of an aneurysm. 
Time, systolic (with apex beat). 
CJtaraeter, expansile in all directions, not simply 

lifting as from a tumor lying upon a large artery. 
Intensity : to detect slight pulsation the light must 

be good. It may sometimes be detected by look- 

ing across the surface. 

Divergence of two projecting objects with each pulsation 
may reveal an otherwise slight expansion — e. g. stick upon 



SIGNS IN THE DISEASES OF THE AORTA. 189 

the surface over the suspected part two small strips of paper, 
so that they may project several inches at right angles from 
the surface. 

DEFICIENT MOVEMENT in the arteries of the left 
side may be seen, especially in aneurysm of the 
transverse part. 

PULSATION OF THE CAROTIDS may be exaggerated. 

APEX BEAT is apt to be displaced downward and 
somewhat to the left with corresponding dislocation 
of the heart. 

EPIGASTRIC PULSATION may be marked with en- 
largement of the right heart as a result of disturbed 
pulmonary circuit. 

RESPIRATORY MOVEMENT may be deficient or ab- 
sent on one side, usually the left, from pressure on 
the main bronchus. 

DYSPNOEA and HYPERPNCEA, amounting to ortho- 
pnoea, may be present, either due to laryngeal paresis 
or to interference with the lungs, trachea, or bronchi 
(especially in aneurysm of the transverse portion). 

COUGH a frequent sign with or without profuse secre- 
tion, variable. 
PALPATIOX. 

AREA OF TENDERNESS over the aneurysm not in- 
frequent, and there may be tender points charac- 
teristic of intercostal neuralgia. 

CONSISTENCE of the tissue over an aneurysm may 
be soft, yielding, and even fluctuating when cartilage 
and bone have been destroyed. 

THRILL systolic over the tumor a frequent sign, some- 
times very early obtained by pressure of the fingers 
in the supra-sternal notch. 

IMPULSE obtained over the tumor usually 
Systolic. 

Diastolic Shock (usually slight) may also be pres- 
ent, due to the falling back of an unusual volume 



190 PHYSICAL DIAGNOSIS OF THE CHEST. 

of blood against the aortic valve, which must be 
competent to give it. (Diastolic shock absent in 
insufficiency of the aortic valve.) 

RADIAL and CAROTID pulse, or both, may be un- 
equal in volume on the two sides owing to pressure 
on the innominate artery or one of its branches, or 
to obstruction by coagulum. 

THE SUPERFICIAL ARTERIES, temporals, radials 
frequently show rigidity, inelasticity, unevenness, 
or tortuosity as a part of general atheroma. 

PULSATION OF THE ABDOMINAL ARTERY and it- 
branches may be very weak in a large aneurysm of 
the descending part of the thoracic aorta. 

tracheal tugging is sometimes an early >ign. 
Dr. \Vm. ESwarts's method of examination : 

Patient seated, head thrown back against exam- 
iner as lie stands behind. Trachea gently 
Stretched by pressure made with tips of both 
index ringers placed under the lower edge of 
the cricoid cartilage. Sensation of traction or 
tugging downward is felt with each heart-beat. 
VOCAL FREMITUS may he diminished over the an- 
eurysm or over the lung, the main bronchus of 
which is obstructed. 
PERCUSSION must he made gently in case of sus- 
pected aneurysm for fear of causing embolism. 
DULNESS is present over the aneurysm. 
SENSATION OF RESISTANCE to the pleximetei 
may be less than over consolidated lung unless the 
aneurysm is filled with fibrin. 
DULNESS OVER THE LUNG may be present also 
when the main bronchus is compressed and the cor- 
responding lung congested or collapsed. Dulness 
over a part of the lung in which consolidation is 
due to pressure or to tuberculosis, which is apt to 
set in where the pulmonary artery is compressed. 



SIGNS IN THE DISEASES OF THE AORTA. 191 

THE HEART is not usually enlarged when the aortic 
valve is unaffected, but it may be displaced. 
A USCUL TA TION. 

MURMUR is present in about half the cases. Fre- 
quently absent in saccular aneurysm (Douglas 
Powell). 

Systolic Bruit most common. In some cases a 
murmur may only be detected by placing the 
chest-piece of the stethoscope in the patient's 
mouth, his lips being closed about it (Sansom). 
The murmur is then conveyed by the trachea. 

Drummond, of New Castle, has noted a systolic murmur 
over the trachea, possibly due to expulsion of air at each 
distention of the aneurysmal sac against the trachea. 
Diastolic Murmur may sometimes be heard over 
a saccular aneurysm independent of aortic re- 
gurgitation, the second aortic sound of the heart 
being clear and loud. This murmur may be due 
to the elastic recoil of the wall of the sac forcing 
the blood back into the aorta, as represented in 
the following diagram : 




Fig. 10.— Illustrating the elastic recoil of an aneurysmal sac, producing a 

diastolic murmur. 

Diastolic Murmur of Aortic Insufficiency, taking 
the place of the second aortic sound, is frequently 
present in aneurysm involving the valves of Val- 
salva. 
VENOUS HUM in the neighborhood of the aneurysm 
may be produced by pressure against a large vein 
or perforation into the vein. It is continuous, and 
apt to be accentuated with each systole. 



192 PHYSICAL DIAGNOSIS OF THE CHEST. 

SECOND AORTIC SOUND is frequently accen- 
tuated and of a ringing, drumming, or clanging 
character, unless replaced by the murmur of in- 
sufficiency. 
RESPIRATORY AND WHISPER AND VOCAL sounds 
may be 
Bronchial over a compressed Lung <>r over the 

aneurysm when resting upon the trachea. 
Diminished or Absent over a whole lung when 
the main bronchus is compressed. 
Forced Inspiration may in such <. ive dis- 

tinct respiratory sounds, absent on ordinary 
respiration. 

COARCTATION OF THE AORTA. 

Definition : a contraction or partial stenosis of the aorta 

(rare). 
Signs. 

INSPECTION reveals evidence of cardiac hypertrophy, 
dilatation of the arch of the aorta and carotid and 
subclavian arteries, and dilatation and tortuosity of 
the superficial arteries. 
PALPATION. 

FEEBLE PULSATION in the abdominal aorta and in 

the arteries of the lower extremities. 
FREMITUS over the large arteries of the head, neck. 
and upper extremities. 
FERCUSSloy negative, 
A USC UL TA TION. 
MURMUR. 

Quality harsh. 
Pitch high. 

Intensity usually loud. 
Time, systolic or diastolic (post-systolic). 
Propagation into the subclavian and carotid ar- 
teries, and it may be heard posteriorly, 



SIGNS IN THE DISEASES OF THE ARTERIES 193 

ANEURYSM OF THE PULMONARY ARTERY. 

Very rare, and difficult of diagnosis, even with the aid of 

subjective manifestations. 
Signs which have been obtained. 
INSPECTION. 

CYANOSIS marked. 

DROPSY. 

DYSPNCEA pronounced. 
PULSATING swelling limited to the second interspace 

to the left of the sternum, where aneurysms of the 

ascending aorta are not as likely to present as those 

of the descending aorta, which commonly present 

posteriorly. 
PALPATION, systolic thrill. 
A USC UL TA TION. 

MURMUR, systolic or diastolic, and not propagated 
above the clavicle. 

ANEURYSM OF THE INNOMINATE ARTERY. 
Signs differ from those of aortic aneurysm in 

LOCATION : it presents to the right of the sternum, 
in the region of the inner end of the clavicle. 

PBESSUHE signs referable to the recurrent laryngeal 
nerve, oesophagus, and trachea are not so apt to oecu/' 
as in aortic aneurysm. 

COMPRESSION, by the examiner, of the carotid and 
subclavian arteries diminishes the pulsation of aneur- 
ysm of the innominate artery, but does not affect aortic 
aneurysm appreciably. 



13 



INDEX. 



Adventitious sounds, 85 
iEgophony, 82 
Alar chest, 36 
Amphoric breathing, 75 

cough, 84 

resonance, 68 

whisper, 83 
Aneurysm of the innominate ar- 
tery, 193 

pulmonary artery, 193 
Angle of Lewis, 32 
Aorta, aneurysm of the, 187 

coarctation of the, 192 

landmarks of the, 30 

sounds over the, 108, 109 
Aortic insufficiency, 173 

obstruction, 117 

pulsation, 46 
in the epigastrium, 50 

valves, 29 
Apex beat, 28, 47 

in emphysema, 121 
Apneumatosis, 123 
Apnoea, 41 
Arterial movements, 45 

sounds, 108, 109 
Asphyxia, 41 
Asthma, signs of, 119 
Atelectasis, 123 
Atrophy, cardiac, 159 
Auscultation, 70, 72 
Axillary lines, 23 



Barrel-shaped chest, 36, 121 

Bell sound, 89 

Blood currents and murmurs, 172 

Bone resonance, 65 

Bradycardia, 55 

Breathing, abnormal, 40 

amphoric, 76 

bronchial, 74 

broncho-cavernous, 75 

cavernous, 75 

cog-wheel, 78 

exaggerated, puerile, 76 

feeble, 77 

interrupted, 78 

laryngeal, 74 

metamorphosing, 75 

normal, 59 
vesicular, 75 

rapidity of, 40 

suppressed, 77 

vesiculocavernous, 75 
Bronchial hemorrhage, 137 
Bronchiectasis, 117 
Bronchi, diseases of, 114 

primary, 28 
Bronchitis, 114-117 
Bronchophony, 81 
Broncho-pneumonia, 128 
Bruit de diable, 110 

Capillary bronchitis, 116 
pulse, 46, 173 

195 



196 



INDEX. 



Cardiac atrophy, 159 

dilatation, 161 

diseases, 153 

dulness, 29, 160 

fatty degeneration, 164 

flatness, 29 

fremitus, 58 

hypertrophy, 160 

lipomatosis, 163 

movements, 47 

rupture, 165 

sounds, 89 
modified, 91 
Carotids, pulsation of, 46 
Cavernous breathing, 75 

cough, 84 

whisper, 83 
Cavity, cracked-metal resonance 
in, 70 

in pulmonary tuberculosis, 131, 
134 
Cerebral blowing, 108 
Chest, form of, 86 

size of, 34 
Chest- wall, diseases of, 112 
Cheyne-Stokes respiration, 42 
Cog-wheel respiration, 78 
Collapsing pulse, 174 
Color, 38 
Costal arch, 20 

breathing, 39 
Cough, varieties of, 83, 84 
Cracked-metal resonance, 70 
Crepitant rales, 84 

in pneumonia, 128 
Crumpling sounds, 87 

Diaphragm and murmurs, 172 
Diaphragmatic breathing, 39 

hernia, 151 

pleurisy, 144 



Diastolic murmurs, 102 

shock in aneurysm, 189 
Diseases of the chest, 112 

heart, 153 

lungs, 143 

pericardium, 153 
Ductus arteriosus, patulous, 1 
Dulness, cardiac, 29, 160 

hepatic, 30 

splenic, 31 

in pulmonary tuberculosis, 132 

pleurisy, 146 

pericarditis, 154 
1 tyspnoea, 40 

in atelectasis, 128 

asthma, 119 

pneumonia, I 5 

Emphysema, pulmonary, 120 

of the chest-wall, 114 
Emphysematous chest, 86, 121 
Empyema pulsans, L9 
Endocardia] murmurs, 
Endocarditis, 167 
Enlarged bronchial gland.-, 142 
Epigastric pulsation, 50 
Eupnoea, 39 

Exocardial murmurs, 94 
Expiratory sound prolonged, 79 

Fatty heart, 163 
Fibroid phthisis, 135 
Insures of the lungs, 25 
Flatness, 51 

cardiac, 29 

hepatic, 30 

in pleurisy, 147 

splenic, 31 
Fontanelle, sounds over the, 108 
Foramen ovale, patulous, 159 
Form of the chest, 36 



INDEX. 



197 



Fremitus, 58-60, 169 
Friction sounds, 88 

pericardiac, 94, 155 

pleuritic, 144 

pleuro-pericardiac, 94 
Friedreich's change of sound, 69 
Functional murmurs, 186 
Funnel breast, 36 

Gerhardt's change of sound, 69 

HiEMO -PERICARDIUM, 157 

Hemothorax, 152 
Harrison's groove, 37 
Heart, aneurysm of the, 165 

congenital anomalies of the, 158 

diseases of the, 153 

fatty, 163 

landmarks of the, 28 

neuroses of the, 166 

parasites of the, 166 

relation to the lungs, 29 

rupture of the, 165 

sounds (see Cardiac), 89 

in pulmonary tuberculosis, 133 

syphilis of the, 165 

thrombosis of the, 166 

tumors of the, 166 

valves of the, 29 
Hepatic dulness, 30 

flatness, 30 

venous pulsation, 46 
Herpes in pneumonia, 125 
Hydatid cysts of the lung, 143 
Hydro-pericardium, 157 
Hydrothorax, 152 
Hyperpncea, 40 
Hypopncea, 41 

Innominate artery, aneurysm 
of the, 193 
landmarks of the, 30 



Inspection, 33 
Inspiratory sound, 79 
Intercostal neuralgia, 112 
Interrupted Wintrich's change of 

sound, 69 
Interval in respiration, 78 

Jugular murmur, 111 
Jugulars, inspiratory swelling of 
the, 156 
presystolic pulsation of the, 45 

Landmarks of the chest, 23 
Lines of reference, 23 
Liver, landmarks of the, 30 

relation to the lungs, 30 
Lobar pneumonia, 124, 128 
Lungs, diseases of the, 114 

fissures of the, 25 

landmarks of the, 24 

lobes of the, 26 

outline of the, 24 

relation to the liver, 30 

Mammillary lines, 23 
Mediastinum, diseases of the, 114 
Mediastinal pericarditis, 156 
Mensuration, 61 
Metallic tinkling, 88 
Metamorphosing breathing, 75 
Mitral insufficiency, 178 

stenosis, 179 

valve, 30 
Movements, 39, 51 

cardiac, 47 

circulatory, 45 

respiratory, 39 
Murmurs, aneurysmal, 191 

aortic diastolic, 103 
systolic, 103 

cardiac, 94 

diastolic, 102 



198 



INDEX. 



Murmurs, endocardial, 95 
exocardial, 94 
functional endocardial, 186 
inorganic, 106 
mitral diastolic, 103 

systolic, 96, 172 
non-valvular, organic, 106 
pulmonic, 101 
transmission of, 171 
tricuspid diastolic, 104 

systolic, 100 
Myocarditis, 162 

Neuroses of the heart, 166 
Normal vesicular breathing, 7:; 

d illness, r>i; 
Nutrition, 83 

Organic MUBMUBS, 96 

Orthopnea, 42 

Palpation, 50 
Para-sternal lines, 23 
Pectoriloquy, whispering, 

Percussion, 61 -(>-'> 
Pericardiac friction Bounds, 94 

splashing sounds, !)4 
Pericarditis, 153 
Phonometry, 112 
Pigeon-breast deformity, 36 
Pleurae, diseases of the, 143 
Pleurisy, cracked-metal resonance 

in, 70 
Pleurodynia, 112 
Pleuro-pericardiac friction sounds, 

94, 144 
Plexor and pleximeter, 61 
Pneumo-hydrothorax, 1 49 
Pneumo-pericardiac sounds, 95 
Pneumo-pericardium, 157 
Pneumothorax, false, 151 
Posture, 37 



Posture in asthma, 119 

in lobar pneumonia, 124 

in pleurisy, 116, 144, 14.*) 
Precordial bulging in pericarditis, 
153 

pulsation, 4!> 
Pulmonary abscess, 189 

apoplexy, 138 

arterial pulsation, 4<> 

artery, aneurysm of the. 193 

cancer, 141 
ipillary pulse, 182 

hemorrhage, 187 

hyperemia, 137 

gangrene, I i" 

insufficiency, l N i 

oedema, 187 
sonance -rated, 65 

iinda in auscultation, 72 
aosis, l 

thrombosis, 138 

tuberculosis, L80 
Pulsation of the epigastrium. 
Pulse, capillary, 4o' 

collapsing, 174 

characteristics, •"> 1 -55 

dicrotic, 54 

in asthma, 1 1!> 

broncho-pneumonia, 129 
lobar pneumonia, 126 

radial, 51 

" water hammer," 174 
Pulsus bigeminus, 54 

paradoxicus, 54 

trigeminus, f)4 
Pyo-pericardium, 157 

Quincke's pulse, 4G 

Rales, varieties of 85 
in asthma, 120 



INDEX. 



199 



Kales in broncho-pneumonia, 130 

in lobar pneumonia, 128 
Regions of the chest, 1-8 
Resonance, amphoric, 68 

cracked-pot, 70 

exaggerated vesicular, 6b 

tympanitic, 67 

vesicular, 64 

vocal, 80 
Respiration (see Breathing), 39 
Respiratory change of sound, 69 

expansion in emphysema, 121 

sounds, 72-78 
Rhachitic chest, 36 

rosary, 36 
Rhonchal fremitus, 59 
Ribs, landmarks of the, 32 

Scapula, landmarks of the, 32 
Shoemaker's breast, 36 
Sibilant rales, 86 
Size of the chest, 34 
Sonorous rales, 86 
Sound, bell, 89 

elements of, 63 
Sounds, auscultatory, 72 

cardiac, 89 

cough, 83 

friction, 88 

percussion, 63 

pleuritic, 144 

pulmonary, 72 

succussion, 89, 111 

tussive, 83 

vascular, 108 

venous, 110, 111 

whispering, 83 
Spinal curvatures, 37 
Spleen, landmarks of the, 31 
Sternal lines, 23 



Stethoscopes, 70, 71 

Subclavian artery, sounds over 

the, 100, 109 
Swellings of the chest- wall, 113 

Tachycardia, 56 
Thrombosis of the heart, 166 
Trachea, 27 
" Tracheal tone," 67 

"tugging," 190 
Tricuspid insufficiency, 184 

stenosis, 186 

valve, position of, 29 
Tuberculosis, acute miliary, 131 
Tumors of the chest- wall, 113 

heart, 166 
Tussive or cough sounds, 83 
Tympany, 67 

Valleix's points of tenderness, 

113 
Valves, cardiac, 29 
Valvular lesions, 173 

murmurs, 96 
Vascular sounds, 108 
Venous hum, 111 

in aneurysm, 191 

pulsation, 45, 174 

sounds, 110 
Vertebrae, landmarks of the, 31 
Vesicular resonance, 64 

respiration, 73 
interrupted, 182 
Vesiculo-tympany in pleurisy, 108 
Vocal fremitus, 60 

sounds, 80 

Whisper, amphoric, 83 

cavernous, 83 
William's tracheal tone, 67, 69 
Wintrich's change of sound, 69 



A TEXT-BOOK 

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